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3. 

5. If you live within the Town Limit’s of Middleburg and would like to have vacation checks performed on your residence, please complete this form, and submit it to the Middleburg Police Department. Twenty-one days is the maximum allowed time for a vacation check. You must notify the department immediately if departure or return times change.

7. Date of Request*
   Date of Request
8. Name*
10. Email*
11. Phone*
13. Residence Address*
15. Date and Time House Will Be Vacant
17. Date/Time Leaving*
    Date/Time Leaving

    Date/Time Leaving
18. Date/Time Returning*
    Date/Time Returning

    Date/Time Returning
20. Location and Phone Where You Are Staying or Cell Phone*

22. Describe vehicles or property left outdoors while on vacation:

24. 1. License Plate #:
25. Make:
27. Model:
28. Year:
29. Color:
31. 2. License Plate #:
32. Make:
34. Model:
35. Year:
36. Color:
38. 3. License Plate #:
39. Make:
41. Model:
42. Year:
43. Color:
45. 4. License Plate #:
46. Make:
48. Model:
49. Year:
50. Color:
52. Other Property:
Leave This Blank:


54. 1. Receive an email copy of this form.
55. Email address

    This field is not part of the form submission.

56. Submit

* indicates a required field