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Racial/Biased Based Profiling Complaint Form

2. First Name*

3. Last Name*

5. Address

7. City

8. State

9. Zip Code

11. Home Phone

12. Alternate Phone Number

    work/cell/other

14. Email

16. Preferred Method of Contact

18. Date & Time of Incident*
    Date & Time of Incident

    Date & Time of Incident

20. Personnel Involved*

    May be a name, description, car number or call number, etc.

22. Description of Incident*

24. Do you wish to file a formal complaint?*

    1. Yes
    2. No

Leave This Blank:


26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit

* indicates a required field