COMPLAINANT INFORMATION |
|
FAMILY NAME: |
|
GIVEN NAME: |
|
MAILING ADDRESS:
|
CITY: |
|
PROVINCE: |
|
POSTAL CODE: |
|
FAX: |
|
HOME TELEPHONE: |
|
WORK TELEPHONE: |
|
CELL TELEPHONE: |
|
OTHER TELEPHONE: |
|
E-MAIL ADDRESS: |
|
PREFERRED LANGUAGE OF CORRESPONDENCE |
|
IF APPLICABLE, NAME AND ADDRESS OF REPRESENTATIVE, LEGAL OR OTHER, FOR THE PURPOSE OF THIS COMPLAINT:
|
PLEASE NOTIFY THE COMMISSION IF YOUR ADDRESS OR PHONE NUMBER CHANGE PRIOR TO THE RESOLUTION OF YOUR COMPLAINT. |
|
CIRCUMSTANCES OF COMPLAINT (PLEASE COMPLETE AS MUCH AS POSSIBLE) |
DATE OF INCIDENT: |
|
TIME OF INCIDENT: |
|
PLACE OF INCIDENT (PROVINCE & CITY): |
|
DID YOU SIGN A FORMAL COMPLAINT ABOUT THIS WITH THE RCMP? |
|
IF YES, WHEN AND WHERE DID YOU SIGN THE COMPLAINT?
|
DID YOU SIGN AN AGREEMENT THAT RESOLVED THIS COMPLAINT INFORMALLY? |
|
PLEASE DESCRIBE ANY INJURIES SUFFERED:
|
WERE PHOTOS TAKEN OF THE INJURIES? |
|
IF YES, WHO TOOK THE PHOTOS?
|
DID YOU RECEIVE MEDICAL TREATMENT FOR YOUR INJURIES? |
|
IF YES, WHAT IS THE NAME OF THE DOCTOR AND HOSPITAL?
|
DO YOU HAVE ANY OTHER EVIDENCE THAT SUPPORTS YOUR COMPLAINT? |
|
IF YES, PLEASE LIST EVIDENCE:
|