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2. Name*
4. Address*
6. City*
7. State*
8. Zip Code*
10. Phone Number*
11. Email Address*
13. Type of Offense
15. When the Violation Occurred*
    When the Violation Occurred

    When the Violation Occurred
17. Street Name Where Violation Occurred*
19. Nearest Cross Street*
21. Additional Comments*
23. Location Type*

    1. Commercial
    2. Residential
    3. School Zone
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25. 1. Receive an email copy of this form.
26. Email address

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27. Submit

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