Jackson Township Police Department

7383 Fulton Drive NW

Massillon OH  44646

Telephone:  (330) 834-3960

Fax:  (330) 834-3965

Home & Business Check Request

(For your convenience, this form may be completed on-line and e-mailed to the Jackson Township Police Department by clicking the submit button after completion; or you can print the form and mail or fax it to the above address/fax number.)

Date Leaving              Time Leaving 

Date Returning           Time Returning 

Type of Check Requested

Name

Common Location

Address

City/State/Zip

Telephone Pager Cell Phone 

Emergency Contact:

Name

Address

City/State/Zip

Does emergency contact have key to this location? Yes No

Will the Lights be left On or Off in the following areas?

First floor lights  On Off   Second floor lights  On Off   Kitchen lights  On Off

Back lights  On Off   Front lights  On Off   Living room lights  On Off

Bedroom lights  On Off

Have you stopped newspaper delivery? Yes No

Have you stopped mail delivery? Yes No

Authorized vehicles on site:

Make Model Color 

Make Model Color 

Make Model Color 

General comments/requests: