Form Center

2. Person/Company/Agency Requesting Service*
   Enter a name
4. Contact Person*
   Enter a name
5. Contact Phone*
   Enter a cell or 24hr contact
7. Billing Address*
   Where should the invoice be sent?
9. Billing City*
10. Billing State*
11. Billing Zip*
13. Job Location*
    Address where police are needed
15. Job Date*
    Job Date Start Date

    Job Date Start Time

    —

    Job Date End Date

    Job Date End Time
    Starting and ending date/time police are needed
17. Type of Event/Duties Needed*
19. # of Officers Requested*
20. Off-Duty/Extra Duty Police Rate

    $55 Per Hour, Per Officer - Payable to City of East Moline

21. Enter Total Cost:*

    # of Officers x Hours x $55

23. Acknowledgement
    Security will be coordinated by the Chief of Police of the City of East Moline. The event organizer and the Police Chief will negotiate a security plan based upon manpower and equipment needs as determined by the Police Chief to ensure the safety and well being of the residents of the City of East Moline as well as any persons attending the event. Payment for police services is due upon receipt of invoice issued by the Finance Department.
25. Electronic Signature*
    Enter your name
Leave This Blank:


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