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2. 
3. Groveland Police Department
   6825 S.R. 50 Groveland, FL 34736
   Ph: 352-429-4166
   Fx: 352-429-5559
   Emergency: 911
4. 
6. Case Number
7. Date and Time of Incident
9. First Name
10. Last Name
11. Phone Number
12. Date of Birth
14. Gender
15. Race
17. Address
19. City
20. State
21. Zip Code
23. Email Address
25. Type of Incident (Domestic, Traffic, Etc.)
27. Witnesses Involved
29. First Name
30. Last Name
31. Phone Number
33. First Name
34. Last Name
35. Phone Number
37. First Name
38. Last Name
39. Phone Number
41. Would you like to be contacted by the Groveland PD

    1. No
    2. Yes
43. Location Type
    -- Select One --BlockIntersectionCommercialResidentialSchool ZoneConstruction Zone
44. Location of Violation
46. City
47. Date of Violation
    Date of Violation

    Date of Violation
49. 
51. Explain in Your Own Words, The Nature of Your Complaint and The Contact Information of Anyone Else Involved or Witness of Any Nature
53. Applicant's Signature
55. Agreement

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    1. I agree.
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58. Email address

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