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2. Information Source
4. Name
5. Email Address
7. Address
9. City
10. State
11. Zip Code
13. Phone Number
14. Fax Number
16. Location of Occurrence:
18. Sheriff's Office Employees Involved:
20. Narrative
    Statements and/or the investigation may conflict with the allegations, are you willing to have a polygraph or voice stress to confirm your statements and the allegations you have made?
22. Please check one

    1. yes
    2. no
24. Name of:*

    1. Complainant
    2. Witnesses
    3. Other
26. Name
27. Email Address
29. Address
31. City
32. State
33. Zip Code
35. Phone Number
36. Fax Number
38. Have you made your report verbally or written to any other officer prior to this form?

    1. yes
    2. no
40. If yes, to whom?
42. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application 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, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
44. Electronic Signature
Leave This Blank:


46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit

* indicates a required field