| Date ........................... |
| Name of Complainant ........................................................................................ |
| Address of Complainant ..................................................................................... |
| Contact Telephone No. ...................................................................................... |
| Name, Rank and Number of the Officer against whom the complaint is being made ............... |
| Particulars of the complaint* ................................................................................ |
| ....................................................................................... |
| ....................................................................................... |
| ....................................................................................... |
| ....................................................................................... |
| * (Continue on a separate sheet if necessary and attach hereto) |
| Received by .................................................................................................... |
| Name and signature .......................................................................................... |
| Date ............................................ |