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PUYALLUP POLICE DEPARTMENT City of Puyallup Public Safety Building - Records Division 311 W. Pioneer Puyallup, WA 98371 (253) 841-5415 Date Leaving: Date Returning: Street Address: Homeowner Name(s): Home Phone: Cell Phone: Other Phone: Alarm System? YES NO If yes, what type? SILENT AUDIBLE If you arrive home earlier than the above stated return date, please call the Puyallup Police Department at (253) 841-5415 so that you can be removed from the house check list. Thank you. Who has key to alarm? Name: Phone: HOUSE CHECK REQUEST FORM HOLD HARMLESS AGREEMENT The undersigned does hereby request the Puyallup Police Department to house check the above residence for the specified period of time that the undersigned is not at their residence. In consideration for this benefit, the undersigned does hereby expressly agree to defend, indemnify, and hold the City of Puyallup, it's officers, officials, employees, and volunteers harmless for any and all claims, injuries, damages, losses or suits including attorney fees, arising out of or in connection with the performance of the agreement except for injuries causes by the sole negligence of the City of Puyallup. Signed this day: Homeowner Signature: * Please complete reverse side * ---PAGE BREAK--- HOUSE CHECK REQUEST FORM cont'd Persons having access to house: Name: Phone: Name: Phone: Lights On? YES NO Using a timer? YES NO Which Rooms: Time lights are scheduled to be on: To: Drapes are? Open Closed Half-Open (Please check only one) Vehicle on property? YES NO If yes, where? How many? Description of vehicle(s) - include make, model, year, color and license plate number: Any other factors that our Officers should be aware of? Total number of days homeowner is gone: Number of foot patrols: Number of spotlight checks: Total number of house checks: * Below for office use only *