BUNKER HILL COMMUNITY COLLEGE
POLICE DEPARTMENT
250 New Rutherford Ave., A-200
Charlestown MA. 02129-2925
Phone 617-228-2053
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Please fill out the form below. Use additional pages for your statement if needed. Provide your name on each page. Once
completed PRINT OUT all pages of the statement form, staple together and submit to BHCC Public Safety Office Room E-127,
Charlestown Campus or Room 107, Chelsea Campus.
Please download this document to your computer saving it and adding your last name to the end (example: Voluntary
Statement Form J Smith.pdf). Fill in all fields, save and then either print and bring it to the office listed above or e-mail the
document, as an attachment, to the address given to you by the staff member you spoke with. You will receive a return e-
mail stating it was received.
VOLUNTARY STATEMENT FORM
I, , volunteer the following information of my own freewill,
for whatever purposes it may serve, t o Officer of the Bunker Hill Community College Police
Department. I am years old and was born on . I reside at:
My
phone number is:
VOLUNTARY STATEMENT
I have just read each page of this statement, consisting of page(s), each page of which bears my
signature, and corrections, if any, bear my initials, and I certify that the facts contained herein are true and
correct to my knowledge. This day of , 20
Person Giving Statement:
OFFICE USE ONLY
Incident # In
take Officer:
