The Keizer Police Department

CHIEF OF POLICE

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Chief of Police - H. Marc Adams

Keizer Police Department Vacation Notification Form

Owners Information: (Click here for a PDF Form)
Owner Names:
Address:
Phone:
Date/Time Leaving:	Date:	Time:
Date/Time Returning	Date:	Time:
Owner may be contacted at:

Special Conditions:

Lights Left On?	Yes No
If lights left on, where?
Timers Used?	Yes No
Keys left with?	Name:	Phone:
Mail Stopped?	Yes No
Other Deliveries?	Yes No	Type:
Persons Authorized on Premises:
Any other conditions you'd like us to know about?

Vehicles Left on Premises:
License #:	State Registered:	Make:	Model:	Color:	Location:

Person to contact locally in case of emergencies:
Name:
Address:
Phone:
Relation:

Name and Drivers License Number of the Requesting Party:
I agree to hold the Keizer Police Department, City of Keizer, Keizer City Council, Employees, Agents, and Servants harmless from any and all liability upon submission of this Vacation Form.
Name:
Date of Birth:
Drivers License Number:	State:
Email Address:

Chief of Police

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