LEO/First Responder Form

For Law Enforcement Officer-First Responder

I have been advised that in all incidents it is to my best interest to speak to my attorney before issuing any statements, and at this moment I am unequivocally asserting my right to remain silent and right to have an attorney present.

My attorney is ___________________________Phone __________________ 

This will provide you personal information that will assist you in your report.

My name is _________________________________DOB_________________

Address_______________________________________________________________

S.S. ________________________ Phone ________________________
Drivers License ____________________________exp______________

________(state) CCW Permit _____________exp_______________

If hurt or arrested - person to contact: _____________________ phone_______________