Close Patrol #___________
Waller County Constable
Department, Pct. 2
Security Check/Close Patrol Request Form
Last Name: _____________________First:________________
Middle:__________Suffix:_______
Address:________________________________________City:__________________Zip:________
Home Phone: (______)____________________Work Phone:
(______)_______________________
Driver’s License Number:________________State:_____________Date
of Birth_______________
Date Leaving:____________________________Date
Returning:____________________________
Emergency Contact Phone:(______)___________________________________________________
Alarm System Activated: ( Y /
N ) Lights on Timer: ( Y / N ) If Yes, Time On: ___ Time Off:___
Alarm Company Name:______________________Phone:
_________________________________
Local Contact Name:_______________________Contact
Phone: (_____)_____________________
Contact’s Address:__________________City:_________________State:___________Zip:_______
Vehicles to be left at Residence:
Make:______________Model:________________Color:______________
Make:______________Model:________________Color:______________
Make:______________Model:________________Color:______________
Location of Vehicles
(Driveway/Garage/Carport/etc.):_____________________________________
Other Items Present Outside
(Boat/Camper/Jet-Ski/etc.):___________________________________
________________________________________________________________________________
Animals/Pets Present:______________________________________________________________
Persons Authorized on Premises(Housekeeper/Caretaker/Maintenance/Lawn
Care/Pool Service/etc.):
_________________________________________________________________________________
_________________________________________________________________________________
Location of Key to the
Building/Residence:______________________________________________
Special
Notes:_____________________________________________________________________
________________________________________________________________________________
_________________________________________________________________________________
________________________
_______________
Signature of Requestor Date