ADDRESS: _____________________________________________________________________

 NAME: ________________________________________________________________________

 Telephone #: ____________________________________________________________________

 DATE LEAVING: _______________________________________________________________

 DATE RETURNING: ____________________________________________________________

 PHONE # YOU CAN BE REACHED AT:____________________________________________

 LOCAL EMERGENCY CONTACT

NAME: _________________________________________________________________________

 ADDRESS: ______________________________________________________________________

 TELEPHONE #: _________________________________________________________________

 CELL PHONE#: _________________________________________________________________

 DOES CONTACT HAVE KEY?    YES     NO

 WILL LIGHTS BE LEFT ON IN THE HOUSE: OUTSIDE: FRONT_______REAR________

 INSIDE: LIVINGROOM_______BEDROOM_______FAMILYROOM_______ OTHER________

 WILL LIGHTS BE ON TIMER? ________

 WILL ANYONE BE IN AND OUT OF HOUSE

NAME:_________________________VEHICLE:_________________________________

VEHICLES AT RESIDENCE: MAKE: ___________________________

PRINT AND TURN IN AT VILLAGE OFFICES

New Lebanon Police DepartmentEmergency Call 9-1-1

198 S. Clayton Road
New Lebanon Ohio 45345

Dispatch 687-3080 
Village Office 687-1341
Montgomery County Municipal Court Western Division 
687-9099
 
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