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2. PINETOP-LAKESIDE POLICE DEPARTMENT
   Volunteers in Policing Program

   Property Watch Request Form

4. Name*
5. Email Address*
7. Address*
9. City*
10. State*
11. Zip Code*
13. Phone Number*
14. Secondary Contact Number*
16. Subdivision
17. Gate Code
18. Combination Code

22. Duration for Property Watch

24. Beginning*
    Beginning
25. End*
    End
29. Reason for Requesting Patrol:*

    Please check one box below:

    1. Seasonal

    1. Vacant

    1. Other
31. If Other, Please Explain:
33. Do you have an alarm system?*
    -- Select One --YesNo
34. Were lights left on?*
    -- Select One --YesNo
36. If Yes, where were the lights left on?
38. Please list all vehicles left at the property:

    Make | Model | Color | Plate Number

40. Any additional information we should know:
42. Please provide 2 local emergency contacts:

    Name | Address | Phone Number

44. Emergency Contact #1*
46. Emergency Contact #2
48. PLEASE NOTE THE FOLLOWING TERMS:
    1. A new Property Watch Request Form must be completed for each renewal.
    2. This application is valid only during the dates given above.
    3. Participants shall hold the VIP program and its volunteers harmless from all liabilities, losses, claims, demands or obligations, and causes of action of any kind, nature, or description, whether known or unknown. 
    4. Access to the property is provided by the property owner. Please use a combination lock ONLY on any entrance gate and supply the combination code at the top of this page. Volunteers will not enter the property if a gate is padlocked. 
    5. The VIP program reserves the right to cancel this entire agreement due to conditions that might put a volunteer at risk.

    The VIP coordinator must be notified of any changes to the above information, or if you return to the property before the end date. CONTACT US at (928) 368-8802 or plpdvips@pinetoplakesideaz.gov

50. Electronic Signature Agreement*

    By checking the "I agree" box below, you acknowledge and agree with the terms stated above. 

    1. I agree.
52. Electronic Signature
54. THE VIP PROGRAM APPRECIATES ANY DONATIONS

    WHICH CAN BE MAILED OR HAND-DELIVERED TO:

    Pinetop-Lakeside Police Department

    1360 N. Niels Hansen Ln. Lakeside, AZ 85929

    *Please write VIP Donation on the memo line of checks made payable to the Police Department*

Leave This Blank:


58. 1. Receive an email copy of this form.
59. Email address

    This field is not part of the form submission.

60. Submit

* indicates a required field