Vacation Patrol Request Check Form

Your Name prefix, Mr or Mrs?

Name *

Address 1 *

Address 2

City *

State *

ZipCode *

Phone Number *

Email Address

Date Leaving *

Date Returning *

Do you have any lights on? *

Yes

No

Location of Lights

Any vehicles in driveway? *

Yes

No

Vehicle Descriptions

Emergency Contact Name *

Emergency Contact Address *

Emergency Contact Phone Number *

Does emergency contact have key? *

Yes

No

Miscellaneous Information

(*) Required fields

Phillips County KS Sheriff's Office
301 State Street, Suite G
Phillipsburg, KS 67661

Phone (785) 543-6885

Email phillipstac@ruraltel.net