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2. First name
3. Last name
5. Date of birth
6. Phone
8. Email
10. Address
12. City
13. State
14. Zip
16. Mailing address (if different from above)
18. The above-named applicant has made the following compliment or complaint:
20. Rank / Name / ID Number
22. The compliment or complaint is based on the following factual information or observations:
24. Date of occurance
25. Time of occurance
27. Location of occurrance
29. Narrative – please include any evidence that you may have:
31. Witnesses, if any:
33. Name
34. Phone
36. Address
38. Name
39. Phone
41. Address
43. Consent to use of Electronic Signature

    1. By checking this box and typing my name below, I am signing this document electronically. I agree that my electronic signature is the legal equivalent of my handwritten signature on this document.
45. 1. Under the penalty of perjury, I do hereby swear and affirm that the information stated herein is true and correct to the best of my knowledge and belief
47. Electronic Signature*
48. Date*
Leave This Blank:


50. 1. Receive an email copy of this form.
51. Email address

    This field is not part of the form submission.

52. Submit Submit and Print

* indicates a required field