2. This form is in place to allow community members the opportunity to alert the Purcellville Police Department to potential traffic problems. If you have a reoccurring traffic problem in your neighborhood that you feel needs attention you can complete this Form or call 540-338-7422 to report it. Information submitted on this form will be sent via email to the following PPD staff members: Deputy Chief, Operations Lieutenant, and the Administrative Lieutenant.
4. Contact 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. Location:*
24. Date and Time
    Date and Time

    Date and Time
26. Nature of Complaint:*
    -- Select One --Traffic LightsSpeedingStop SignsSchool Bus ViolationsOther
28. Please explain in detail the events of the complaint.*
30. 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.
32. 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.
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34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

* indicates a required field