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Request For Residence Check

  1. REQUEST FOR RESIDENCE CHECK
  2. AREA: _______________

    FOR OFFICIAL USE ONLY

  3. FORM SUBMITTED ONLINE
  4. STREET ADDRESS / CITY / ZIP

  5. YES or NO - IF YES, NAME(S) / ADDRESS / PHONE #

  6. NAME(S) / ADDRESS / PHONE #

  7. YES or NO - IF YES, INSIDE or OUTSIDE

  8. YES or NO - IF YES, INSIDE or OUTSIDE

  9. YES or NO

  10. YES or NO - IF YES, MAKE / COLOR / TAG #

  11. 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.

  12. DATE / TIME:
  13. REMARKS ABOUT RESIDENCE:
  14. OFFICER'S INITIALS / ID#:
  15. Leave This Blank:

  16. This field is not part of the form submission.