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2. Today's Date and Time
   Today's Date and Time

   Today's Date and Time
3. I am a

   1. Private Citizen
   2. Police Officer
5. First Name
6. Last Name
8. Address1
10. Address2
12. City
13. State
14. ZIP
16. E-mail Address
18. Home Phone Number
19. Cell Phone Number
21. Date and Time of Incident *
    Date and Time of Incident

    Date and Time of Incident
22. Location of Incident*
    Please provide address, street, intersection
24. Any Vehicle Informaiton
26. Any Other Witnesses To The Event
28. Name and Badge Number (if known) of Officer(s) involved
30. Preferred Contact method

    1. Home Phone
    2. Cell Phone
    3. Text
    4. Email
32. Are You makign the Commendation/Complaint in reference to:*

    1. Yourself
    2. Another Individual
34. Description*
    Please enter your statement below, including any name(s), location(s) of the incident, vehicle descriptions, license plates, and any otehr witnesses. Please be as specific as possible.
Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

* indicates a required field