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2. First Name*
3. Last Name*
4. Phone Number*
6. Address 1*
7. City*
8. State
10. Zip*
11. Email Address*
12. Is this a commercial request?*

    1. Yes
    2. No
14. Type of Report

    1. Eloy Adult Arrest Record Search
    2. Traffic Accident
    3. Crime Type
15. Crime Type
17. Purpose of Request

    1. Victim
    2. Witness
    3. Insurance Claim
    4. Other
18. Items Requested*

    Please describe the public records you wish to receive. In order to expediate the search for the records, please be as specific as possible.

20. Police Report Number
21. Date/Time Reported
22. Exact Date/Time Reported
23. Location of Incident
25. Nature of Incident*

    1. Accident
    2. Accident with Injury
    3. Assault
    4. Auto Theft
    5. Bicycle Theft

    1. Burglary
    2. Theft
    3. Recovery
    4. Other
26. If Other Please Explain
28. Person on Record Name
29. Date of Birth
31. Do you agree?*

    By clicking ?I agree,? you agree and acknowledge that 1) your application will not be "Signed" in the sense of a traditional paper document and 2) By signing in this alternate manner, you agree that your ?electronic signature? is valid and binding upon you to the same force and effect as a handwritten signature.

    1. I Agree
33. Signature of person making the request
    The City will respond to this request withing five (5) working days.
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42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit Submit and Print

* indicates a required field