Black Butte Ranch Police Department
PO Box 8244
Black Butte Ranch, Oregon

541/595-2191
Fax 541/595-1033
E-mail:  bbrpd@bendcable.com

VACATION CHECK REQUEST

Section              

Lot #        Street  
Owner Name Ranch Phone
  		Email
 
Departure Date  Return Date     


EMERGENCY CONTACT INFORMATION :

Name           Phone Number  
Address         


EXPECTED USE OF RESIDENCE BY ANYONE OTHER THAN HOMEOWNER 

Date of Use   Name of Occupant   Relationship  
Date of Use   Name of Occupant   Relationship  
Date of Use   Name of Occupant   Relationship  

Vehicles left at residence

Make   Color   License #  
Make   Color   License #  
Make   Color   License #  


Is anyone checking your residence?   When   
Who    Phone   
Who has keys to the residence  
Any lights on ?    Timers   
Alarms?     

Is your residence on the Maintenance Department Inspection Program?  

Any additional comments or instructions....

   
 
Upon returning to Black Butte Ranch, please notify the Police Department 595-2191.

If anyone should use your residence in your absence,
please advise them to  notify this department as soon as they enter the Ranch and again when they leave.
 

For CONFIDENTIALITY your Vacation Request Form
will be transmitted through a Secure Socket Line (SSL) where the information will be encrypted