Report of Citation or Arrest | FORM

REPORT OF CITATION/ARREST
Employee Name*
First Last
Date Reported*
MM slash DD slash YYYY
Location Reported or Citation Received at*
City State / Province / Region
Was this in a personal vehicle or a company vehicle?*
- Personal
- Company
CBO Number*

Charter Booking Order, Trip Number, Charter Number
Bus or Equipment Number*
Date Cited*
MM slash DD slash YYYY
Violation(s) (Vehicle Code/Other)*
Speed Cited*
Posted Speed*
Citation Number*
Court Appearance Date
MM slash DD slash YYYY
Police Information
Officer's Name*
First Last
Badge Number*
What department was this?*
- City Police
- County Sherriff
- State or Highway Patrol
- Other
Please explain*
Police Department*
City State / Province / Region
Request Speedometer Check*
- Yes
- No
Last four of SS Number*
Signature

REPORT OF CITATION/ARREST