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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