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Brazoria Police Department Request for Offense/Accident/Incident/Call Sheet

Date
Date
**This information MAY or MAY NOT be available at the time requested or MAY NOT be available for PUBLIC INSPECTION.
First Name*
Last Name*
Representing Firm or Company Name
Email Address
Address*
City*
State*
Zip Code*
Phone Number*
Fax Number
Driver's License #*
State License Held*
Description of Offense Report(s) or Public Record(s) being requested, Please include any dates of Offense, Names, and Dates of birth of persons involved in Offense(s):
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.
1. I agree.
Electronic Signature
If you have any questions concerning this form or required payment of requested items, please contact The Department Administrative Assistant at 979-798-2195 ext 305.

Leave This Blank:

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

This field is not part of the form submission.
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