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Complaint Against On-Duty Security Personnel

Name of Complainant:


Address you can be contacted at: (required field)




Cell Phone:


Home Phone:


Work Phone:


Date of Incident:


Time of Incident:


Location of Incident: (required field)


Name of officer against whom complaint is being filed:


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



Badge Number:


Vehicle Number:


Other Identification:


Other witnesses (names, addresses, phone numbers):


Statement of allegation: (required field)


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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