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2. 1. Contact Information
4. First Name*
5. Last Name*
7. Address*
9. City*
10. State*
11. Zip Code*
13. Email Address*
14. Phone Number*
16. Today's Date*
18. 2. Name of employee (or description if not known)*
20. 3. Location of Incident*
22. 4. Date of incident*
23. 5. Time of incident*
25. 6. Description of Incident*
27. 7. Please list any witnesses. Pease provide their name, telephone number, or other contact information.
29. 8. Is there a police report/incident number?
    -- Select One --YesNo
30. If yes, please provide that incident number.
32. 9. Is there a citation number or arrest?
    -- Select One --YesNo
33. If there is a citation, please provide the citation number.
35. 10. Do you have video or photographs of this incident? If yes, please be prepared to provide it when you are contacted by the Davidson Police Department.
    -- Select One --YesNo
37. Would you like to receive a copy of your submission?
    -- Select One --YesNo
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39. 1. Receive an email copy of this form.
40. Email address

    This field is not part of the form submission.

41. Submit

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