| Student: |
yes
no |
Incident #: |
|
| Last Name: |
|
First Name: |
|
| Middle: |
|
Date of Birth: |
|
| Local Address: |
(street / residence hall) |
| City: |
|
State:
Zip:
|
| Local Phone: |
|
Home Phone: |
|
Cell Phone: |
|
| Home Address: |
|
| City: |
|
State:
Zip:
|
| Date of Statement: |
|
Time of Statement:
AM
PM |
| I hereby make the following voluntary statement to: |
|
| Who has identified himself/herself to me as a member of the University Police. No threats or promises have been made to me to cause me to make this statement. I do so of my own free will. |
|
| I have read (or had read to me) the above statement and find it is true and correct to the best of my knowledge and belief. |
| Signature:
|
Date:
|
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