Name of Complainant :
(required field)

At what address can you be contacted?:

Home phone number:

Work phone number:

Date of incident:

Time of incident:

Location of incident: *

Name of officer against whom complaint is being filed:

Or other identifying marks (car number, badge number, etc.)
Rank:

Badge#:

Vehicle#:

Other identification: *

Other witnesses (names, Addresses, Phone Numbers):*

Statement of allegation:*

*These text areas are limited to 210 characters; if you need to send additional information, please send an email, that includes your name and date of incident, to:
Tony Crouch
Vice President of Business Services

I understand that this Complaint will be submitted to the Director of Campus Security and may be the basis for an investigation. I declare that the information contained herein is accurate and true to the best of my knowledge and belief. Further, I declare and affirm that this statement is made by me voluntarily without coercion of any kind.