EHBEMS Commendation - Complaint Form
Reporting Party's Name: Phone Number:
Address: City: State: Zip: ??????????????
Email:
Witness Name: Witness Phone:
Type of Incident:
Location of Incident:
Date of Incident: Time of Incident:
Officer/Personnel Involved (if known):
Nature of Commendation or Complaint (Briefly state the nature of commendable action or complaint. What is it that one or more of our members did, or failed to do? What were the conditions or circumstances at the time of the incident, and what resulted?):
Please Sign and Date:
Full Name: Today's Date??????:
Acknowlagement of Submission:
I confirm that the above information is accurate and true:
