#FFFFFF Name and Date of Birth First Name Last Name Date of Birth Sex - None - Email Address Email Address Confirm Email Address Telephone Number Name of OTB or Racetrack Date and Time of Incident Date and Time of Incident: Date Date and Time of Incident: Time Name of Employee You Dealt With Narrative I understand that this report is being made to peace officers of the State of Colorado and declare that all information provided with this submission is true to the best of my knowledge and belief. I further understand that if I have knowingly made false statements or intentional misrepresentations that I will be prosecuted according to law Submit Leave this field blank
