Form Center

2. Notice
   Return date cannot exceed 120 days from departure date. If your return date is in excess of 120 days, you or your designee must submit a new form. You may request a security check in person, by phone (708) 447-2127.
4. Type*

   1. Residence

   1. Business

   1. Other
6. Departure Date*
   Departure Date
7. Return Date*
   Return Date
   Not to exceed 120 days
9. Owner/Tenant*
10. Phone Number*
12. Address to be Checked*
    Riverside, Illinois
14. Any Light Timers?*

    1. Yes
    2. No
15. Keys left with anyone?*

    1. Yes
    2. No
16. Someone working at address during absence?*

    1. Yes
    2. No
18. Names of the individuals
20. In an emergency who should be notified?*
21. Phone Number*
23. Address*
25. City*
26. State*
27. Zip Code
29. Phone Number where you can be reached in an emergency*
31. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
     
    4) The Village of Riverside, Riverside Police Department and any of its assigned agents, thereto, accept no responsibility for continuous protection of the above-listed property in your absence. General protection will be given as per statute for all property owners within the Village, hovever specialized personal, selective police protection is not part of the agreement.
     
    

    1. I agree.
33. Electronic Signature
34. Date/Time*
    Date/Time

    Date/Time
Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

* indicates a required field