| First Name: |
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| Last Name: |
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| Address Street 1: |
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| Address Street 2: |
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| City: |
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| Zip Code: |
(5 digits) |
| State: |
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| Daytime Phone: |
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| Evening Phone: |
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| Email: |
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| Date of Incident / Misconduct |
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| Time of Incident / Misconduct: |
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| Location of Incident / Misconduct: |
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| Officer Name (If Known): |
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| Nature of Complaint: |
Criminal Activity |
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Beligerant / Rude |
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Non Performance of Duty |
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Other |
| If Other Please Explain: |
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