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Name of Complainant :
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:
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:
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.
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