2. Please include as much information as possible in the form. Incomplete or inaccurate information will delay processing of this report and may compromise our ability to quickly and effectively respond to this complaint. Thank you.
4. 1. Please tell us where the problem is
6. Address*
   The address must be entered correctly for the report to be processed, a misspelled or incomplete entry will return a negative response.
8. City*
9. State*
10. Zip Code*
12. 2. Please select where the activity occurs at the location given in section 1
14. Identify the activity location for this violation*

    1. Alley or Driveway
    2. Garage
    3. Hallway / Corridor
    4. Inside Business
    5. Inside Private Residence
    6. Other Activity Location
    7. Park / Wooded Area
    8. Sidewalk / Street Corner
    9. Vacant Lot
    10. Vehicle
15. If "Other" is selected, please specify
17. 3. Please tell us about the security at this location
    Help us determine what we're up against so we can take the necessary precautions. If you don't know, please leave this section blank.
19. Have you seen guns at this location?

    1. Yes
    2. No
20. Are there dogs at this location?

    1. Yes
    2. No
22. 4. Please tell us about the activity
24. Activity Nature*

    1. Cocaine
    2. Heroin
    3. Other
    4. Marijuana
25. If "Other" is selected, please specify
27. Days when activity is present*

    Select all that apply, do not exaggerate - we will be using this information to verify the report

    1. Monday
    2. Tuesday
    3. Wednesday
    4. Thursday
    5. Friday
    6. Saturday
    7. Sunday
28. Times when activity is present*
    Times when activity is present Start Time

    —

    Times when activity is present End Time
30. Describe the activity*
    Use this area to tell us about the activity being reported. Explain as much in detail about the situation as you can. Remember, you can't tell us too much!
32. 5. Please tell us about the drug dealer or distributor
    If you know the drug dealer's name, description, current address or phone number, please provide it.
34. Dealer's Name
35. Dealer's Nickname
37. Dealer's Age
    Enter the approximate age of the primary age of the Offender at this location. You may enter an age range. Example: 20-25 years
38. Dealer's Race and Sex
40. Dealer's Phone Number
41. Dealer's Pager Number
43. Dealer's Address
45. City
46. State
47. Zip Code
49. Dealer's Description
    Please describe the violator's appearance. Include scars, tattoos, clothes, jewelry descriptions, hair styles and any other distinguishing marks. If you can't provide a description enter "Unknown" in this space.
51. 6. Please tell us about any vehicle used by the participants
    Use this area to tell us about any vehicles used by the participants of this activity.
53. Vehicle Type
    -- Select One --CarOtherTruck
54. Vehicle Year
    An approximate year is acceptable, if it's a newer car please mention that.
56. Vehicle Manufacturer
    For example, Ford, Chevrolet, Honda, Cadillac
57. Vehicle Model Name
    For example, Escort, Camaro, Civic, El Dorado
59. Vehicle Color
60. License Plate State
    If you don't know the state, please describe the color.
62. License Number
    If you only know part of it, please enter it.
64. Unique Features
    Describe any unique features like damaged parts, accessories, sun roofs, etc. The idea is to give us a unique description of the car so we can immediately recognize it.
66. 7. Please tell us about yourself
    This area is completely optional. You do not have to provide this information to us. If you decide to, we will use it only to contact you for additional information. This information will be kept strictly confidential.
68. First Name
69. Last Name
71. Address
73. City
74. State
75. Zip Code
77. Daytime Phone
78. May we call you for additional information?

    1. Yes
    2. No
80. Email Address
82. Additional Comments
Leave This Blank:


84. 1. Receive an email copy of this form.
85. Email address

    This field is not part of the form submission.

86. Submit

* indicates a required field