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2. Because of the nature of law enforcement, we understand that citizens on occasion may object to the actions of the police, or may feel their conduct is inappropriate. Therefore, we have established procedures for citizens to report their concerns to the Department. Part of this procedure includes accepting and reviewing this form. Information submitted on this form will be sent via email to the following PPD staff members: Chief, and Deputy Chief only.
4. Complainants Information
6. First Name
7. Middle Initial
8. Last Name
10. Address1
12. Address2
14. City
15. State
16. Zip
18. Phone:
19. Email:
21. Complaint Information
23. Incident Location:*
24. Date and Time*
    Date and Time

    Date and Time
26. Details of the complaint.*
28. Witness Contact Information
30. First Name
31. Middle Initial
32. Last Name
34. Address1
36. Address2
38. City
39. State
40. Zip
42. Phone:
43. Email:
45. Please be aware that information submitted through the Town of Purcellville Government website is considered a Public Record under the Virginia Public Records Act, and may be subject to release by the Town in response to a request made under the Virginia Freedom of Information Act.
47. Do not submit any unsolicited personally identifiable information including (but not limited to) your: (1) social security number; (2) driver's license number; (3) bank account numbers; (4) credit or debit card numbers; (5) personal identification numbers (PIN); (6) electronic identification codes; (7) automated or electronic signatures; or (8) passwords; or (9) any other numbers or information that can be used to access your assets, obtain identification, act as identification, or obtain goods or services.
Leave This Blank:


49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit

* indicates a required field