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Request Police Record

2. First Name

3. Last Name

5. Address1

7. City

8. State

9. Zip

11. Email Address*

12. Phone Number

14. Description of Request

    Provide a detailed description of the records that you are requesting. Be as specific as possible.

16. Request Options
    -- Select One --I am requesting a report involving myselfI am requesting a report involving my child I was involved in a traffic crash I am an insurance agent/representative investigating an insurance claimI am an attorney/law firm representing a client in anticipation of litigationOther (specify in Description of Request)

    Please select one

Leave This Blank:


18. 1. Receive an email copy of this form.
19. Email address

    This field is not part of the form submission.

20. Submit

* indicates a required field