SESSION |
|
*REQUIRED INFORMATION.
|
Make sure you have all the information you need to complete your report. Upon approval, a copy of your report will be sent to your e-mail address. |
*AUTOSEQ |
|
INCID |
|
*Last Name
|
|
*First Name
|
|
Middle Initial
|
|
*Street Address
|
|
*City
|
|
*State
|
error: Server returned HTTP response code: 400 for URL: http://localhost:82/mrcjava/servlet/POLEXT.I00020s?reqtype=5&listtl=Select%20a%20State&is_import=Y
|
*Zip Code
|
|
Date of Birth
|
(ex. 12/01/1995) |
Gender
|
Female
Male
|
Home Phone
|
|
Cell Phone
|
|
Business Phone
|
|
*E-mail Address
|
|
Date and Time of Incident
|
|
*Location of Incident
|
Include cross streets |
Description of Incident/Narrative (describe what happened)
|
|
Do you wish to receive a case number via e-mail?
|
Yes
No
|
INCDESC
|
|
APPNAME
|
|