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Name
Email Address
Address
City
State
Zip Code
Phone Number
Date of Birth
Are you submitting this form on behalf of another person?
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1. No
Date of Incident*
Date of Incident
Approximate Time of Incident*
Approximate Time of Incident
Location of Incident*
GJPD Incident Number
Name or Badge Number of Involved GJPD Personnel
Please summarize your experience.*
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.)
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Were there witnesses to this incident?
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Witness Name
Phone Number
Witness Name
Phone Number
Witness Name
Phone Number