2. Reporting Party Information
4. First Name
5. Last Name
7. Your Address
9. City
10. State
11. Zip Code
13. Preferred Telephone Number*
14. Preferred Time to Call
16. Your Email Address
20. Incident Information
22. Date of Incident
23. Time of Incident
24. AM / PM

    1. AM
    2. PM
26. Police Report Incident Number
27. Police Citation Number
29. Location of Incident
31. Employee Name
32. Badge Number
34. Details
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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