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2. Date: *
   Date:

   Date:
4. First Name: *
5. Last Name: *
7. Main Phone Number: *
8. Alternate Phone Number:
10. Email Address: *
12. Name of Event:*
14. Location of Event:
15. Type of Event:
17. Date of Event:
    Date of Event:
18. Beginning Time of Event:
    Beginning Time of Event:
19. Ending Time of Event:
    Ending Time of Event:
21. Cancellation Details:

    In addition to the form, notifications of cancellations can be made to the Administrative Coordinator at 305-891-0294 Ext. 24013, Monday through Friday, from 9 AM to 4 PM, excluding holidays. If you are unable to call during the listed hours, you may email the Administrative Coordinator at dsimillien@northmiamipolice.com. Failure to complete this form, canceling your request for off-duty police services within 24 hours, will require a payment of three (3) hours per officer and/or supervisor assigned to the detail. 

    If you should have any questions, please contact the Administrative Coordinator at, 305-891-0294 Ext. 24014.

    Sign and submit this document by clicking below. Upon signing this form, you agree to the aforementioned requirements.

23. 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.

    1. I agree.
25. Electronic Signature
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