Official Statement Form - Public Safety

Name(Required)

First Last

Email(Required)

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Phone(Required)

Date of Birth(Required)

GCC Status(Required)

Student

Employee

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Department(Required)

Your Statement(Required)

This narrative statement should reflect a truthful and accurate account of events to the best of your knowledge. Please include relevant details such as the date, time, location, individuals involved and any witnesses. Information provided may be reviewed by authorized personnel and become part of an official record.

Please Confirm

I hereby make this statement freely, knowingly and voluntarily to the Greenfield Community
College Public Safety Department. By submitting this statement, I affirm and certify, under penalty of perjury, that the facts and information contained herein are true and correct to the best of my knowledge and belief.

I confirm