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2. Town Of Chino Valley Police Department

   Phone:  (928) 636-4223 option 2
   Email:  pdrecords@chinoaz.net

4. First Name*
   Name of Requestor
5. Last Name*
7. Date of Request
9. Driver's License #
10. State
11. Contact Telephone #*
13. Mailing*
15. Physical*
17. City*
18. State*
19. Zip*
21. DR# (report #)
    (e.g. 15c-00000)
22. All names involved, include DOB's
24. Date of Incident
25. Type of Incident
    (e.g. Accident, Harassment, Sex Offense, etc.)
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27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit Submit and Print

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