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Complaint Against On-Duty Security Personnel

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.)



Other identification: *

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

Statement of allegation:*

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.

Campus Security
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