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2. First Name*
3. Last Name*
5. Address*
7. City*
8. State*
9. Zip Code*
11. Phone*
13. Case Number (if applicable)
15. Type of Request:*

    1. Extra Patrol
    2. New Move-In (Residence)
    3. New Business
17. Reason for Request
    -- Select One --Suspicious ActivityPrevious BurgalryTheftVandalismOther
19. Dates / Times*
    Dates / Times

    Dates / Times
21. Any Notes / Describe Why
23. Specific People or Cars to Watch for
25. Acknowledgement of Terms

    I agree as a condition of submission to release, defend, indemnify and hold the City of South Jordan, its officers, agents, employees and volunteers harmless from and against any and all loss, judgments, damages, or expenses, arising from or incurred by reason of any claim, lawsuit or action in law or equity, based upon property damage or theft to the property listed on this submission, except to the extent that such injury or damage is directly caused by the negligent acts or omissions of the City of South Jordan, its officers, agents, employees or volunteers resulting from my request for this service.

    1. I read and have acknowledged the terms
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27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

* indicates a required field