Fillable Chevy Chase Village Police Department (Town of Chevy Chase Village)

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Chevy Chase Village Police Department (Town of Chevy Chase Village)

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11/2016
Oce Use Only Date/Time Received:________________ Inials & ID:__________
CCV 406
Chevy Chase Village Police Department
5906 Connecticut Avenue, Chevy Chase, Maryland 20815
(301) 654-7300
Compliment/Complaint Form
Instructions:
1. Fill out form. Please print or type legibly.
2. Complaints alleging excessive force must be signed and sworn to under penalty of perjury.
3. Submit/mail this form to 5906 Connecticut Avenue, Chevy Chase, Maryland 20815.
4. You will be contacted upon receipt of the Compliment/Complaint form.
Your Name:
Date:
Date of Birth:
Race:
Home Phone:
Cell Phone:
Address:
Apt. Number:
City:
State:
Zip Code:
Location or address where incident occurred:
Date of Incident:
Time:
Incident# (if known):
1.Witness’ Name:
Phone Number:
Address:
2.Witness’ Name:
Phone Number:
Address:
Name(s) of employee(s) involved:
Describe what happened:
Please use reverse side of this form if more space is needed.
Signature:
Check One:
Compliment ☐ Complaint ☐
11/2016
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Chevy Chase Village Police Department (Town of Chevy Chase Village)

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Completed 2 August 2020

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