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2. Date of Incident:*
   Date of Incident:
3. Time of Incident:*
   Time of Incident:
5. Location of Incident:*
7. Date Reported:*
   Date Reported:
8. Time Reported:*
   Time Reported:
12. Complainant Information
14. First Name*
15. Last Name*
17. Address1*
19. Address2
21. City*
22. State*
23. Zip*
25. Phone Number:*
26. Email Address:*
30. Witness Information
32. First Name
33. Last Name
35. Address1
37. Address2
39. City
40. State
41. Zip
43. Phone Number
44. Email Address
48. Additional Witness Information
50. First Name
51. Last Name
53. Address1
55. Address2
57. City
58. State
59. Zip
61. Phone Number
62. Email Address
66. Police Department Officer/Employee
68. First Name (if known)*
69. Last Name (if known)*
71. Employee Department (please select one)*
    -- Select One --Uniformed Police OfficerNon-Uniformed Police OfficerDispatcherOther Employee
73. Additional Police Department Employee
75. First Name (if known)
76. Last Name (if known)
78. Employee Class (please select one)
    -- Select One --Uniformed Police OfficerNon-Uniformed Police OfficerDispatcherOther Employee
80. Describe the details surrounding your complaint: *
84. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your complaint 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.

    1. I agree
86. Complainant's Signature (type name)*
87. Date signed:*
    Date signed:
Leave This Blank:


88. 1. Receive an email copy of this form.
89. Email address

    This field is not part of the form submission.

90. Submit Submit and Print

* indicates a required field