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Appealing Party Information

Name(s) of Carbondale Police Officer(s) or Firefighter(s) associated with Complaint:
Name:*
Name:
Name:
Name:
Name:
Name:
If name(s) of Carbondale Police Officer(s) or Firefighter(s) complained of is unknown, provide description including sex, race, hair color, eye color, and approximate height, weight, and age.
Where did incident occur?*
What date did incident occur?*
What time did the incident occur (approximately)?*
Date original Complaint was submitted*
Date Response to original Complaint was received*
Reason for Appeal submission*
Did anyone witness this incident? If so, please include witness information below.*
1. Yes
2. No
Name
Phone
Email
Address
Name
Phone
Email
Address
Name
Phone
Email
Address
Electronic Signature Agreement and Certification*
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
Certification:
I hereby certify that all of the statements contained in the Complaint Appeal form are true and correct to the best of my knowledge and belief.
1. I agree.
Electronic Signature*
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