2. Neighborhood Watch
4. Community Name*
6. Coordinator's Name*
   Full Legal Name
7. Coordinator's Phone*
   817-123-4567
9. Address*
   1234 Main Street
10. Email*
12. It should be understood that due to the nature of the Neighborhood Watch program, applicants should be reliable and trustworthy. For the protection of all concerned, the Grapevine Police Department requires the above information. All information contained above is completely confidential. I, the undersigned, hereby authorize the Grapevine Police Department to inquire and determine whether or not I have ever been investigated, charged or convicted of a criminal offense. I further authorize the Department to obtain a full and complete disclosure of all the facts uncovered. I have provided the above information for such an inquiry and affirm that I am of good character. This original will be retained by the Grapevine Police Department. The Grapevine Police Department reserves the right to revoke Neighborhood Watch status.
14. Electronic Signature*
    Full Legal Name
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16. 1. Receive an email copy of this form.
17. Email address

    This field is not part of the form submission.

18. Submit

* indicates a required field