2. Instructions
   The purpose of this form is to submit a complaint of misconduct against an employee of the Athens-Clarke County Police Department. If you need to file a police report or speak to an officer about criminal activity, please call 706-546-5900.
4. Your First Name*
5. Your Last Name*
7. E-mail Address*
8. Cell Phone Number*
9. Home Phone Number
11. Address 1
13. City
14. State
15. Zip
17. Date of Birth
18. Race

    1. White/Caucasian
    2. Black/African American
    3. American Indian/Alaska Native
    4. Asian
    5. Native Hawaiian/Pacific Islander
    6. Prefer Not to Say
19. Gender

    1. Male
    2. Female
    3. Other
    4. Prefer Not to Say
21. Occupation
22. Employer
23. Employer Contact Number
27. Incident Date and Time*
    Incident Date and Time

    Incident Date and Time
28. Incident Location*
29. Case Number (If Known)
31. Please describe basis for complaint or allegation of misconduct*
35. 1st Officer Name
36. ACCPD Vehicle #
37. Badge # (If Known)
39. 1st Officer Description
40. 1st Officer Race
41. 1st Officer Gender
45. 2nd Officer Name
46. ACCPD Vehicle #
47. Badge # (If Known)
49. 2nd Officer Description
50. 2nd Officer Race
51. 2nd Officer Gender
55. 3rd Officer Name
56. ACCPD Vehicle
57. Badge # (If Known)
59. 3rd Officer Description
60. 3rd Officer Race
61. 3rd Officer Gender
63. Additional Information
65. Affirmation*

    I HEREBY AFFIRM THAT THE FOLLOWING INFORMATION PROVIDED BY ME IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF.

    Type your name above to indicate you have read and understand the affirmation. 

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66. 1. Receive an email copy of this form.
67. Email address

    This field is not part of the form submission.

68. Submit

* indicates a required field