Personal Information

Name*: Email*:

Telephone* Fax

Current Address (Street, City, State, Zip)*:
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Witness Information

Witness #1

Name: Email:

Telephone Fax

Current Address (Street, City, State, Zip):
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Witness #2

Name: Email:

Telephone Fax

Current Address (Street, City, State, Zip):
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Witness #3

Name: Email:

Telephone Fax

Current Address (Street, City, State, Zip):
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Incident Details

Date/Time of Incident* Location of Incident*

Name of officer(s) or employee(s) against whom the complaint is being filed. If no names or known, please describe any identifying information about the officer, employee, vehicle or badge numbers involved*:

Please describe your allegation of complaint in the space below*:

* Required

By clicking below on the submit button I understand that this statement of complaint will be submitted to the Longwood University Public Safety and may be the basis for an investigation. Further, I affirm that the facts contained herein are complete, accurate, and true to the best of my knowledge. Further, I declare and affirm that my statement has been made by me voluntarily without persuasion, coercion, or promise of any kind.

I understand that, under the regulations of the department, the employee against whom this complaint is filed may be entitled to a hearing. By signing and filing this complaint, I hereby agree to appear before a hearing board, if one is requested by the employee, and to testify under oath concerning all matters relevant to this complaint.

I have read and agree to the terms above.