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  1. Complete This Portion If Complainant Is A Minor Or If Assisted By Another Person.
  2. Identity Of Involved Personnel
  3. Brief Narrative Of Occurrence Using Your Own Words. Any Questions, Call The Office Of Professional Services At (478) 449-8843.
  4. Witness Information
  5. Electronic Signature Agreement
    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
  6. I have read and understood this statement, which I have made of my own free will and the facts contained therein are true and correct to the best of my knowledge.
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  8. This field is not part of the form submission.