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2. For the purpose of tracking the usage, please indicate whether or not you have previously completed an online survey for the Jacksonville Police Department.

   1. Yes

   1. No
4. Type of Request
   -- Select One --Safety PresentationNeighborhood WatchCrime PreventionAlcohol / Drug / TobaccoTour of JPDOther (Specify Below)
6. If you chose "Other," please specify:
8. Requested Date & Time
   Requested Date & Time

   Requested Date & Time
9. Location
11. Type of Group
12. Number Attending
14. Name of Person Making Request
15. Organization / Contact Number
17. Email
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19. 1. Receive an email copy of this form.
20. Email address

    This field is not part of the form submission.

21. Submit

* indicates a required field