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* 1. First Name

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* 2. Last Name

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* 3. Would you like to remain anonymous?

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* 4. Phone Number

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* 5. Email

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* 6. Address

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* 7. City

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* 8. Zip code

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* 9. Languages spoken at home:

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* 10. Race

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* 11. What subject(s) is this submission regarding for the Suffolk County Police Department:

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* 12. Please add a detailed response regarding the subject(s) you've checked here

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* 13. What prompted you to submit today?

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* 14. Do you have any attachments you would like to include?

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* 15. Add attachment

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