Canby Police Department

Vacation House Form







Fill out the form below. Once you click SUBMIT, we will receive your information via email. If you'd rather print this form click HERE. Fill out the form and then drop it off or mail it to us at Canby Police Department, 122 N. Holly, Canby OR 97013. For Canby residents only.

If, before you leave you wish an officer to check your home to see that it is secure, please feel free to call us as we are available 24 hours a day, and would be happy to render this service.

The purpose of this form is to let us know, in the event of an emergency, that your home is vacant. It will also give us a resource to call if there is a problem at your home while you are gone. The information on the form will be placed on a log where officer's will be made aware that your home is vacant.



General Information
Today's Date
Departure Date
Return Date
Name
Address
Phone
Emergency Contact Name
Emergency Contact Phone
Have Keys
 Yes No
House Details
Does House Have An Alarm System? Yes No
Does Alarm Have An Automatic Shut-Off? Yes No
Are There Dogs On Site? Yes No
Have You Arranged For Daily Deliveries To Be Stopped? Yes No
Is Anyone Authorized To Be On The Premises? Yes No
Authorized Visitor Name
Authorized Visitor's Phone
Authorized Visitor's Reason
Vehicles At Residence                                           (1) License Number
  Description
                                                                             (2)
 License Number
  Description
                                                                             (3) License Number
  Description
Condition Of House Upon Departure (Indicate anything that might cause someone to believe a crime has occurred, i.e. broken windows, torn or cut screens, etc...)
Will There Be Lights, Radio, TVs, Etc... Left On? Yes No
Are They On Timers? Yes No
Approximate On/Off Times

Thank you, and have a save trip!

This Data Will Be Destroyed Within Seven (7) Days After Your Stated Return Unless Otherwise Arranged
Submissions may not be received by our department until the next business day.