New London Police Department 5 Governor Winthrop Blvd. New London, CT 06320 P: (860) 447-5269	F: (860) 701-3474 W: NewLondonPolice.com Records Section

PRIVATE DUTY REQUEST

Company/Billing Information

Company Name:

Point of Contact:

POC Mobile Phone:	POC Office Phone:

Billing Agent/Corporation:

Billing Address:

Billing Office Phone:	Mobile:

Purchase Order/Work Order Number:

Job Information

Date:	Start Time:	End Time:

Number of Officers Needed:	Number of Cars Needed:

Job Location:

Brief Description of Job:

Have you hired a NL Officer in the Past? Yes No

Is this job an emergency: Yes No

Requestor Name:

Date of Request:

Title of Requestor: