Incident Occured:                       Date: (MM/DD/YYYY)                 Time: (HH:MM AM/PM)
       between:                                                                          

Last Name: First Name: Middle:

Home Address: City:

State:    TX AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NE NC ND NH NJ NM NV NY OH OK OR PA RI SC SD TN UT VA VT WA WI WV    Zip: Home Phone: Work Phone:

Driver of the Vehicle:

Last Name: First Name: Middle:

Driver's ID/Tag Number

Race: Sex: Male Female   Ht: Wt: Hair color/length:

Eye color: Approximate Age:

Was the Employee in Uniform?
Yes   No   Unsure  
Vehicle Description:   Make: Model License Plate
                                       Vehicle Number Company Name

Anything unusual (for example: glasses, mustache or tattoos)

Please Give a brief description of the incident:

I affirm that this information is true and correct
Your signature

You should receive a confirmation e-mail of receipt of your complaint within 10 working days from submission. If you do not receive any confirmation or you have any further questions please contact the El Paso Police Department’s Vehicle for Hire Unit at 564-7056 Monday through Friday 8:ooam to 4:00pm.