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2. Contact Information
4. Today's Date and Time
   Today's Date and Time

   Today's Date and Time
6. Name
7. Date of Birth
   Date of Birth
9. Address
11. City
12. State
13. Zip Code
15. Phone Number
16. Email Address
18. Remain Anonymous?*

    1. Yes
    2. No
20. May an investigator contact you for additional information?*

    1. Yes
    2. No
24. Incident Information
26. Location of Activity
28. Names of Those Involved (if Known)
30. Places of Employment of Those Involved (Include Shifts if Known)
32. Types of Drugs (if Known)
34. Day(s) of the Week When Most Activity Seems to Occur
36. Timeframe When Most Activity Occurs (Please Be as Specific as Possible)
38. Vehicles Spotted at Scene of Suspected Drug Activity (Make, Model, Color and License Plates)
40. Other Details
42. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
44. Electronic Signature
Leave This Blank:


46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit

* indicates a required field