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2. Name
3. Email Address
5. Address
7. City
8. State
9. Zip Code
11. Phone Number
12. Preferred Method of Contact

    1. Email
    2. Phone
    3. Do not contact me
16. I would like to make a:

    1. Commendation
    2. Complaint
    3. Suggestion
17. Date and Time of Incident (if Applicable)
    Date and Time of Incident (if Applicable)
19. Please indicate what initiated your contact with the Rome Police Department:

    1. Made a report at the Police Department
    2. Picked up Property at the Police Department
    3. Police Response to your call
    4. Traffic Accident
    5. Traffic Stop
    6. Visit a Detective
    7. Witness for a Police Investigation
    8. Other
21. If other, please specify
25. Officer's Name
26. Officer's Badge Number
28. Witness Name
29. Witness Phone
31. Witness City
32. Witness State
33. Witness Zip
37. Please Describe in Detail your Commendation, Complaint, or Suggestion:
Leave This Blank:


39. 1. Receive an email copy of this form.
40. Email address

    This field is not part of the form submission.

41. Submit

* indicates a required field