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2. 
4. Name
5. Email Address
7. Address
9. City
10. State
11. Zip Code
13. Phone Number
14. Date of Birth
16. Are you submitting this form on behalf of another person?

    1. Yes

    1. No
20. Date of Incident*
    Date of Incident
21. Approximate Time of Incident*
    Approximate Time of Incident
23. Location of Incident*
25. GJPD Incident Number
26. Name or Badge Number of Involved GJPD Personnel
28. Please summarize your experience.*
30. If you have video or photos of this incident, please upload them here.
    (If file size is larger than 25MB, please email the files to gjpd@gjcity.org.)
32. Would you like someone to contact you about this incident?*

    1. Yes

    1. No
34. How would you like to be contacted?
    -- Select One --Phone (preferred)Email
38. Were there witnesses to this incident?

    1. Yes

    1. No
40. Witness Name
41. Phone Number
43. Witness Name
44. Phone Number
46. Witness Name
47. Phone Number
Leave This Blank:


49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit

* indicates a required field