2. Complainant Information
4. First Name*
5. Last Name*
7. Address*
9. City*
10. State*
11. Zip*
13. Home Phone*
14. Mobile or Work Phone
16. Email*
17. Driver License Number*
19. Place of Employment*
20. Driver License State*
    -- Select One --AlabamaAlaskaArizonaArkansasColoradoConnecticutDelawareFloridaGeorgia HawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
22. Other Contact Information
24. Incident Information
26. Address of Incident*
28. City*
29. State*
30. Zip*
32. Date of Incident*
33. Time*
35. Officer or Employee Involved
36. Badge or ID #
38. Officer or Employee Involved
39. Badge or ID #
41. Nature of Incident
43. I certify that the information provided in this report is true and accurate to the best of my knowledge. I further understand that making a false report to a police officer is a criminal offense*

    1. I Agree
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45. 1. Receive an email copy of this form.
46. Email address

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47. Submit

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