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2. Date of Request
3. Request # (to be filled out by FPD personnel)________________________
5. Contact Information for Person Making Request
7. Name
9. Address (Street, City, State, Zip)
11. Phone Number
12. Ext
14. Fax #
15. Email
17. Request Information
19. Defendant Name
21. Incident Date/Time
23. Arresting Officer
25. Involved Officers
27. Brief Description of Incident (helps us to locate the correct footage)
29. Police Dept Case #
30. Location of Arrest
32. Charge
34. Vehicle Info (Make, Year, Model, Color, Plate#, State)
36. THIS SECTION TO BE COMPLETED BY THE IT DIVISION
38. Date received by IT Division __________________
40. Video available: ____Yes ____No
42. If unavailable, reason:
44. Date completed: _____________
45. Completed by: __________________
47. Requester notified that DVD is ready to be picked up.
49. Date: ____________
50. Name: ____________________________________________________________
52. ADM 006 004
Leave This Blank:


54. 1. Receive an email copy of this form.
55. Email address

    This field is not part of the form submission.

56. Submit Submit and Print

* indicates a required field