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2. When Not to Use This Form
   IF YOU BELIEVE THE INCIDENT YOU WISH TO REPORT IS A CRIME, RATHER THAN USE THIS FORM, PLEASE CALL (207) 721-4300 OR 9-1-1 IF THIS IS AN EMERGENCY.
4. Complainant Contact Information
   If you wish, you can report the incident anonymously. However, if you would like to be contacted about your complaint, or are willing to provide more information about the incident being reported if need be, please provide as much of the personal information below as you are willing to provide.
6. Name
7. Email Address
9. Address
11. City
12. State
13. Zip Code
15. Phone Number
16. Fax Number
20. Date and Time of Incident*
    Date and Time of Incident

    Date and Time of Incident
21. Location of Incident*
23. What Type of Bias?
    -- Select One --RaceColorReligionAncestryNational OriginGenderPhysical DisabilityMental DisabilityNational OriginOther
24. Description of Other Bias
    Please describe what type of bias you are reporting.
26. Please describe the bias incident with as much detail as possible (names, descriptions, license plates, etc.)
Leave This Blank:


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

    This field is not part of the form submission.

30. Submit

* indicates a required field