Special Duty Request Form

Special Duty Request Form

Powell Police Department 47 Hall St. Powell, OH 43065 614-885-5005
Requesting Person

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Company/Group Name
Date of Event

MonthDayYear
Date
Start Time

Hour Minutes

AM/PM Option
End Time

Hour Minutes

AM/PM Option
Name of Event and Location
Number of Participants
On Scene Contact

First NameLast Name
Phone Number
Please enter a valid phone number.
Type of Event
Tax Forms Required for Payment
Alcohol Present
Number of Officers Requested
Police Cruiser Needed
Special Requests
Standard Officer Pay Rate: $50.00/ hour

Holiday Officer Pay Rate: $100.00/hour (See Below)

Supervisor Rate: $55.00 or $110/ hour (Holiday) -this rate is required when requesting 4 or more officers

Police Cruiser Rate: $15.00/hour (No Minimum)

3 Hour Minimum

Construction Cancellation Policy: 2 hours

Special Event Cancellation Policy: 72 hours
Designated Holidays requiring Premium Pay
- New Year's Day
- Martin Luther King Day
- President's Day
- Memorial Day
- Independence Day
- Labor Day
- Thanksgiving & Day After
- Chiristmas Eve
- Christmas Day
- New Year's Eve
This is a contract with the individual Powell Police Officer(s) who work the event. Payment is due at the conlusion of the event, unless approval is given by the Special Duty Coordinator or designee for payment no later than 10 business days after the event. Payment may be cash, check, or money order. Failure to remit full payment on time could result in the suspension of future special duty request priviledges and/or civil action. By signing this contract, I agree to make payment for services rendered as detailed in this contract. Must be 18 years of age.

To cancel a request call 614-885-3374.
Signature

Clear
Date of Request

MonthDayYear
Date
Should be Empty: