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Complainant's Information |
First Name: |
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Middle Name: |
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Last Name: |
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Email Address: |
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Sex: |
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Date of Birth: |
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Home Address: |
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Home Phone Number: |
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Business Address: |
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Business Phone Number: |
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Additonal Complainant Information |
Full Name: |
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Phone Number: |
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Address: |
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Additonal Complainant Information |
Full Name: |
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Phone Number: |
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Address: |
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Incident Description |
Nature of Complaint: |
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Location of Occurance: |
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Date of Incident: |
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Time of Incident: |
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Accused Employee Name: |
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Badge ID Number: |
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Assignment: |
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Description of Complaint:
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Complainant's Certification |
I swear or affirm that the above information is factual and correct. I understand that if said facts and allegations are proven to be false I may be prosecuted under Minnesota Criminal Code Chapter 609.48 - Perjury (A felony punishable by imprisonment for not more than five years or a fine of not more than $10,000, or both) and/or other applicable law and possibly subject to civil liability. I certify that the foregoing complaint is true and correct and that my signature acknowledging the same is a free act and deed.
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Today's Date: |
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Full Name: |
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Please note: you may be required to submit a handwritten signature, in person, before your electronic form can be processed. We will contact you if your handwritten signature is required for processing. |
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