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Submitted URL: https://a032-secure.nyc.gov/
Effective URL: https://a032-secure.nyc.gov/p/ofcomplaint.html
Submission: On October 23 via api from US — Scanned from DE
Effective URL: https://a032-secure.nyc.gov/p/ofcomplaint.html
Submission: On October 23 via api from US — Scanned from DE
Form analysis 1 forms found in the DOM
POST ./action/action_complaint.php
<form data-toggle="validator" role="form" action="./action/action_complaint.php" method="post" id="complaint_form" novalidate="novalidate" class="bv-form">
<!-- START of complaint information------------------------------------------------------------------------------------------------------------------------>
<!-- START of complaint information------------------------------------------------------------------------------------------------------------------------>
<div class="panel panel-default">
<div class="panel-heading">YOUR INFORMATION</div>
<div class="panel-body">
<div>
<p>All fields with an asterisk <span class="fieldRequired">*</span> are required, but any additional information you can provide will help us to process your complaint.</p>
</div>
<div class="form-group has-feedback">
<label><span class="fieldRequired">*</span>How did you learn about DOI?</label>
<div class="radio"><label><input type="radio" id="complainant_know_doi_via" name="complainant_know_doi_via" value="Advertisements" required="" data-bv-field="complainant_know_doi_via">Advertisements</label></div>
<div class="radio"><label><input type="radio" id="complainant_know_doi_via" name="complainant_know_doi_via" value="Corruption Lecture" data-bv-field="complainant_know_doi_via">Corruption Lecture</label></div>
<div class="radio"><label><input type="radio" id="complainant_know_doi_via" name="complainant_know_doi_via" value="Internet" data-bv-field="complainant_know_doi_via">Internet</label></div>
<div class="radio"><label><input type="radio" id="complainant_know_doi_via" name="complainant_know_doi_via" value="Family/Friend"
data-bv-field="complainant_know_doi_via"><i class="form-control-feedback" data-bv-icon-for="complainant_know_doi_via" style="display: none;"></i>Family/Friend</label></div>
<small data-bv-validator="notEmpty" data-bv-validator-for="complainant_know_doi_via" class="help-block" style="display: none;">Please select an option</small>
</div>
<div class="form-group has-feedback">
<label><span class="fieldRequired">*</span>Are you a City Employee?</label>
<div class="radio"><label><input type="radio" name="complainant_is_city_employee" value="Yes" data-bv-field="complainant_is_city_employee"> Yes</label></div>
<div class="radio"><label><input type="radio" name="complainant_is_city_employee" value="No"
data-bv-field="complainant_is_city_employee"><i class="form-control-feedback" data-bv-icon-for="complainant_is_city_employee" style="display: none;"></i> No</label></div>
<small data-bv-validator="notEmpty" data-bv-validator-for="complainant_is_city_employee" class="help-block" style="display: none;">Please select an option</small>
</div>
<div id="complainant_city_agency_show_hide" style="display:none;">
<div class="well">
<div class="form-group">
<label>Select City Agency</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-list"></i></span>
<select class="form-control" id="complainant_city_agency" name="complainant_city_agency">
<option value="" selected="" disabled="">Choose a City Agency </option>
<option value="Administration for Children Services (ACS)">Administration for Children Services (ACS)</option>
<option value="Board of Election (BOE)">Board of Election (BOE)</option>
<option value="Board of Estimate (BDEST)">Board of Estimate (BDEST)</option>
<option value="Board of Standards and Appeals (BSA)">Board of Standards and Appeals (BSA)</option>
<option value="Borough President – Bronx">Borough President – Bronx</option>
<option value="Borough President – Brooklyn">Borough President – Brooklyn</option>
<option value="Borough President – Manhattan">Borough President – Manhattan</option>
<option value="Borough President – Queens">Borough President – Queens</option>
<option value="Borough President – Staten Island">Borough President – Staten Island</option>
<option value="Business Integrity Commission (BIC)">Business Integrity Commission (BIC)</option>
<option value="Campaign Finance Board (CFB)">Campaign Finance Board (CFB)</option>
<option value="City Clerk's Office">City Clerk's Office</option>
<option value="City Council">City Council</option>
<option value="City Marshal">City Marshal</option>
<option value="City Sheriff (Sheriff)">City Sheriff (Sheriff) </option>
<option value="City University of New York (CUNY)">City University of New York (CUNY)</option>
<option value="Civil Service Commission (CSC)">Civil Service Commission (CSC)</option>
<option value="Civilian Complaint Review Board (CCRB)">Civilian Complaint Review Board (CCRB)</option>
<option value="Commission on Human Rights (CCHR)">Commission on Human Rights (CCHR)</option>
<option value="Community Board – Manhattan">Community Board – Manhattan</option>
<option value="Community Board – Brooklyn">Community Board – Brooklyn</option>
<option value="Community Board – Bronx">Community Board – Bronx</option>
<option value="Community Board – Queens">Community Board – Queens</option>
<option value="Community Board – Staten Island">Community Board – Staten Island</option>
<option value="Conflicts of Interest Board (COIB)">Conflicts of Interest Board (COIB)</option>
<option value="Department for the Aging (DFTA)">Department for the Aging (DFTA)</option>
<option value="Department of Buildings (DOB)">Department of Buildings (DOB)</option>
<option value="Department of City Planning (DCP)">Department of City Planning (DCP)</option>
<option value="Department of Citywide Administrative Services (DCAS)">Department of Citywide Administrative Services (DCAS)</option>
<option value="Department of Consumer Affairs (DCA)">Department of Consumer Affairs (DCA)</option>
<option value="Department of Correction (DOC)">Department of Correction (DOC)</option>
<option value="Department of Cultural Affairs (DCLA)">Department of Cultural Affairs (DCLA)</option>
<option value="Department of Design & Construction (DDC)">Department of Design & Construction (DDC)</option>
<option value="Department of Education (DOE)">Department of Education (DOE)</option>
<option value="Department of Environmental Protection (DEP)">Department of Environmental Protection (DEP)</option>
<option value="Department of Finance (DOF)">Department of Finance (DOF)</option>
<option value="Department of Health & Mental Hygiene (DOHMH)">Department of Health & Mental Hygiene (DOHMH)</option>
<option value="Department of Homeless Services (DHS)">Department of Homeless Services (DHS)</option>
<option value="Department of Housing Preservation & Development (HPD)">Department of Housing Preservation & Development (HPD)</option>
<option value="Department of Information Technology & Telecommunications (DoITT)">Department of Information Technology & Telecommunications (DoITT)</option>
<option value="Department of Investigation (DOI)">Department of Investigation (DOI)</option>
<option value="Department of Parks & Recreation (Parks)">Department of Parks & Recreation (Parks)</option>
<option value="Department of Probation (DOP)">Department of Probation (DOP)</option>
<option value="Department of Records & Information Services (DORIS)">Department of Records & Information Services (DORIS)</option>
<option value="Department of Sanitation (DSNY)">Department of Sanitation (DSNY)</option>
<option value="Department of Small Business Services (SBS)">Department of Small Business Services (SBS)</option>
<option value="Department of Transportation (DOT)">Department of Transportation (DOT)</option>
<option value="Department of Youth & Community Development (DYCD)">Department of Youth & Community Development (DYCD)</option>
<option value="Department of Youth & Family Justice (DYFJ)">Department of Youth & Family Justice (DYFJ)</option>
<option value="District Attorney – Manhattan (NYDA)">District Attorney – Manhattan (NYDA)</option>
<option value="District Attorney – Brooklyn (BKDA)">District Attorney – Brooklyn (BKDA)</option>
<option value="District Attorney – Queens (QNDA)">District Attorney – Queens (QNDA)</option>
<option value="District Attorney – Bronx (BXDA)">District Attorney – Bronx (BXDA)</option>
<option value="District Attorney – Richmond (SIDA)">District Attorney – Richmond (SIDA)</option>
<option value="Economic Development Corporation (EDC)">Economic Development Corporation (EDC)</option>
<option value="Emergency Medical Services (EMS)">Emergency Medical Services (EMS)</option>
<option value="Financial Information Services Agency (FISA)">Financial Information Services Agency (FISA)</option>
<option value="Fire Department (FDNY)">Fire Department (FDNY)</option>
<option value="Health and Hospitals Corporation (HHC)">Health and Hospitals Corporation (HHC)</option>
<option value="Human Resources Administration (HRA)">Human Resources Administration (HRA)</option>
<option value="Human Rights Commission (HRC)">Human Rights Commission (HRC)</option>
<option value="Independent Budget Office (IBO)">Independent Budget Office (IBO)</option>
<option value="Landmarks Preservation Commission (LPC) ">Landmarks Preservation Commission (LPC) </option>
<option value="Law Department (LAW)">Law Department (LAW)</option>
<option value="Mayor's Office">Mayor's Office </option>
<option value="New York City Comptroller's Office">New York City Comptroller's Office</option>
<option value="New York City Housing Authority (NYCHA)">New York City Housing Authority (NYCHA)</option>
<option value="New York City Employees Retirement System (NYCERS)">New York City Employees Retirement System (NYCERS)</option>
<option value="New York City School Construction Authority (SCA)">New York City School Construction Authority (SCA)</option>
<option value="Office of the Actuary (NYCOA)">Office of the Actuary (NYCOA)</option>
<option value="Office of Administrative Trials and Hearings (OATH)">Office of Administrative Trials and Hearings (OATH)</option>
<option value="Office of Chief Medical Examiner (OCME)">Office of Chief Medical Examiner (OCME)</option>
<option value="Office of Collective Bargaining (OCB)">Office of Collective Bargaining (OCB)</option>
<option value="Office of Management & Budget (OMB)">Office of Management & Budget (OMB)</option>
<option value="Office of the Mayor (MAYOR)">Office of the Mayor (MAYOR)</option>
<option value="Office of Payroll Management (OPA)">Office of Payroll Management (OPA)</option>
<option value="Police Department (NYPD)">Police Department (NYPD)</option>
<option value="Procurement Policy Board (PPB)">Procurement Policy Board (PPB)</option>
<option value="Public Administrator – New York (PANY)">Public Administrator – New York (PANY)</option>
<option value="Public Administrator – Bronx (PABX)">Public Administrator – Bronx (PABX)</option>
<option value="Public Administrator – Brooklyn (PABK)">Public Administrator – Brooklyn (PABK)</option>
<option value="Public Administrator – Queens (PAQN)">Public Administrator – Queens (PAQN)</option>
<option value="Public Administrator – Richmond (PASI)">Public Administrator – Richmond (PASI)</option>
<option value="Public Advocate – (PUBADV)">Public Advocate – (PUBADV)</option>
<option value="Rent Guidelines Board (RGB)">Rent Guidelines Board (RGB)</option>
<option value="Tax Appeals Tribunal">Tax Appeals Tribunal</option>
<option value="Tax Commission (TC)">Tax Commission (TC)</option>
<option value="Taxi & Limousine Commission (TLC)">Taxi & Limousine Commission (TLC)</option>
</select>
</div>
</div>
<div class="form-group">
<label>Title (Include Rank and Shield Number if Applicable)</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-user"></i></span>
<input type="text" class="form-control" id="complainant_title" name="complainant_title" placeholder="Enter your job title" maxlength="75">
</div>
</div>
</div> <!-- end of well div -->
</div> <!-- end of the hide div -->
<div class="well well_light_blue">You may make your complaint anonymously; however, to help DOI process your complaint, please consider providing a way for us to contact you if there are follow-up questions.</div>
<script>
function jsfunction2() {
grecaptcha.reset();
grecaptcha.execute();
}
function onSubmit() {
return new Promise(function(resolve, reject) {
console.log(grecaptcha.getResponse());
document.getElementById('singlebuttonid').click();
//Instead of using 'return false', use reject()
//Instead of using 'return' / 'return true', use resolve()
resolve();
}); //end promise
}
</script>
<div class="form-group has-feedback">
<label><span class="fieldRequired">*</span>Do you wish to remain anonymous?</label>
<div class="radio"><label><input type="radio" name="complainant_remain_anonymous" value="Yes" data-bv-field="complainant_remain_anonymous"> Yes</label></div>
<div class="radio"><label><input type="radio" name="complainant_remain_anonymous" value="No"
data-bv-field="complainant_remain_anonymous"><i class="form-control-feedback" data-bv-icon-for="complainant_remain_anonymous" style="display: none;"></i> No</label></div>
<small data-bv-validator="notEmpty" data-bv-validator-for="complainant_remain_anonymous" class="help-block" style="display: none;">Please select an option</small>
</div>
<div id="complainant_anonymous_show_hide">
<div class="well">
<div class="form-group has-feedback" id="zzzzz1">
<label><span class="fieldRequired" id="complainant_first_name_required_label">*</span>First Name</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-user"></i></span>
<input type="text" class="form-control" id="complainant_first_name" name="complainant_first_name" placeholder="Enter your first name" maxlength="50"
data-bv-field="complainant_first_name"><i class="form-control-feedback" data-bv-icon-for="complainant_first_name" style="display: none;"></i>
</div>
<small data-bv-validator="notEmpty" data-bv-validator-for="complainant_first_name" class="help-block" style="display: none;">Please enter your first name</small><small data-bv-validator="stringLength"
data-bv-validator-for="complainant_first_name" class="help-block" style="display: none;">This value is not valid</small>
</div>
<div class="form-group has-feedback">
<label><span class="fieldRequired" id="complainant_last_name_required_label">*</span>Last Name</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-user"></i></span>
<input type="text" class="form-control" id="complainant_last_name" name="complainant_last_name" placeholder="Enter your last name" maxlength="50"
data-bv-field="complainant_last_name"><i class="form-control-feedback" data-bv-icon-for="complainant_last_name" style="display: none;"></i>
</div>
<small data-bv-validator="notEmpty" data-bv-validator-for="complainant_last_name" class="help-block" style="display: none;">Please enter your last name</small><small data-bv-validator="stringLength"
data-bv-validator-for="complainant_last_name" class="help-block" style="display: none;">This value is not valid</small>
</div>
<div class="form-group has-feedback">
<label>Company Name</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-tower"></i></span>
<input type="text" class="form-control" id="complainant_company_name" name="complainant_company_name" placeholder="Enter your company name" maxlength="75"
data-bv-field="complainant_company_name"><i class="form-control-feedback" data-bv-icon-for="complainant_company_name" style="display: none;"></i>
</div>
<small data-bv-validator="stringLength" data-bv-validator-for="complainant_company_name" class="help-block" style="display: none;">This value is not valid</small>
</div>
<div class="form-group">
<label>Address:</label>
<div class="input-group">
<label class="radio-inline"><input type="radio" name="complainant_address" value="Home">Home</label>
<label class="radio-inline"><input type="radio" name="complainant_address" value="Business">Business</label>
</div>
</div>
<div class="form-group has-feedback">
<label for="complainant_street_address">Street Address</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-home"></i></span>
<input type="text" class="form-control" id="complainant_street_address" name="complainant_street_address" placeholder="Enter your street address" maxlength="50"
data-bv-field="complainant_street_address"><i class="form-control-feedback" data-bv-icon-for="complainant_street_address" style="display: none;"></i>
</div>
<small data-bv-validator="stringLength" data-bv-validator-for="complainant_street_address" class="help-block" style="display: none;">This value is not valid</small>
</div>
<div class="form-group has-feedback">
<label for="complainant_apt_number">Apt#/Room/Floor/Suite </label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-home"></i></span>
<input type="text" class="form-control" id="complainant_apt_number" name="complainant_apt_number" placeholder="Enter your Apt#/Room/Floor/Suite" maxlength="75"
data-bv-field="complainant_apt_number"><i class="form-control-feedback" data-bv-icon-for="complainant_apt_number" style="display: none;"></i>
</div>
<small data-bv-validator="stringLength" data-bv-validator-for="complainant_apt_number" class="help-block" style="display: none;">This value is not valid</small>
</div>
<div class="form-group has-feedback">
<label for="complainant_city_town">City</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-home"></i></span>
<input type="text" class="form-control" id="complainant_city_town" name="complainant_city_town" placeholder="Enter your City" maxlength="50"
data-bv-field="complainant_city_town"><i class="form-control-feedback" data-bv-icon-for="complainant_city_town" style="display: none;"></i>
</div>
<small data-bv-validator="stringLength" data-bv-validator-for="complainant_city_town" class="help-block" style="display: none;">This value is not valid</small>
</div>
<div class="form-group">
<label for="complainant_state">State</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-list"></i></span>
<select class="form-control" id="complainant_state" name="complainant_state">
<option value="" selected="" disabled="">Choose a State </option>
<option value="Alabama">Alabama</option>
<option value="Alaska">Alaska</option>
<option value="Arizona">Arizona</option>
<option value="Arkansas">Arkansas</option>
<option value="California">California</option>
<option value="Colorado">Colorado</option>
<option value="Connecticut">Connecticut</option>
<option value="Delaware">Delaware</option>
<option value="District of Columbia">District of Columbia</option>
<option value="Florida">Florida</option>
<option value="Georgia">Georgia</option>
<option value="Hawaii">Hawaii</option>
<option value="Idaho">Idaho</option>
<option value="Illinois">Illinois</option>
<option value="Indiana">Indiana</option>
<option value="Iowa">Iowa</option>
<option value="Kansas">Kansas</option>
<option value="Kentucky">Kentucky</option>
<option value="Louisiana">Louisiana</option>
<option value="Maine">Maine</option>
<option value="Maryland">Maryland</option>
<option value="Massachusetts">Massachusetts</option>
<option value="Michigan">Michigan</option>
<option value="Minnesota">Minnesota</option>
<option value="Mississippi">Mississippi</option>
<option value="Missouri">Missouri</option>
<option value="Montana">Montana</option>
<option value="Nebraska">Nebraska</option>
<option value="Nevada">Nevada</option>
<option value="New Hampshire">New Hampshire</option>
<option value="New Jersey">New Jersey</option>
<option value="New Mexico">New Mexico</option>
<option value="New York">New York</option>
<option value="North Carolina">North Carolina</option>
<option value="North Dakota">North Dakota</option>
<option value="Ohio">Ohio</option>
<option value="Oklahoma">Oklahoma</option>
<option value="Oregon">Oregon</option>
<option value="Pennsylvania">Pennsylvania</option>
<option value="Rhode Island">Rhode Island</option>
<option value="South Carolina">South Carolina</option>
<option value="South Dakota">South Dakota</option>
<option value="Tennessee">Tennessee</option>
<option value="Texas">Texas</option>
<option value="Utah">Utah</option>
<option value="Vermont">Vermont</option>
<option value="Virginia">Virginia</option>
<option value="Washington">Washington</option>
<option value="West Virginia">West Virginia</option>
<option value="Wisconsin">Wisconsin</option>
<option value="Wyoming">Wyoming</option>
</select>
</div>
</div>
<div class="form-group has-feedback">
<label for="complainant_zip_code">Zip Code</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-home"></i></span>
<input type="text" class="form-control" id="complainant_zip_code" name="complainant_zip_code" placeholder="Enter your zip code" maxlength="5"
data-bv-field="complainant_zip_code"><i class="form-control-feedback" data-bv-icon-for="complainant_zip_code" style="display: none;"></i>
</div>
<small data-bv-validator="zipCode" data-bv-validator-for="complainant_zip_code" class="help-block" style="display: none;">Please enter a valid zip code or leave it blank</small><small data-bv-validator="stringLength"
data-bv-validator-for="complainant_zip_code" class="help-block" style="display: none;">This value is not valid</small>
</div>
<div class="form-group has-feedback">
<label><span class="fieldRequired" id="complainant_primary_phone_required_label"> </span>Primary Phone</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-phone"></i></span>
<input type="text" class="form-control input-medium bfh-phone" data-format=" (ddd) ddd-dddd" id="complainant_primary_phone" name="complainant_primary_phone" maxlength="15"
data-bv-field="complainant_primary_phone"><i class="form-control-feedback" data-bv-icon-for="complainant_primary_phone" style="display: none;"></i>
</div>
<small data-bv-validator="phone" data-bv-validator-for="complainant_primary_phone" class="help-block" style="display: none;">Please enter a valid phone number with area code</small><small data-bv-validator="stringLength"
data-bv-validator-for="complainant_primary_phone" class="help-block" style="display: none;">This value is not valid</small>
</div>
<div class="form-group has-feedback">
<label><span class="fieldRequired" id="complainant_secondary_phone_required_label"> </span>Secondary Phone</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-phone"></i></span>
<input type="text" class="form-control input-medium bfh-phone" data-format=" (ddd) ddd-dddd" id="complainant_secondary_phone" name="complainant_secondary_phone" maxlength="15"
data-bv-field="complainant_secondary_phone"><i class="form-control-feedback" data-bv-icon-for="complainant_secondary_phone" style="display: none;"></i>
</div>
<small data-bv-validator="phone" data-bv-validator-for="complainant_secondary_phone" class="help-block" style="display: none;">Please enter a valid phone number with area code</small><small data-bv-validator="stringLength"
data-bv-validator-for="complainant_secondary_phone" class="help-block" style="display: none;">This value is not valid</small>
</div>
<div class="form-group has-feedback">
<label><span class="fieldRequired" id="complainant_email_required_label"></span>Email Address</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-envelope"></i></span>
<input type="text" class="form-control" id="complainant_email" name="complainant_email" placeholder="Enter your email address" maxlength="75"
data-bv-field="complainant_email"><i class="form-control-feedback" data-bv-icon-for="complainant_email" style="display: none;"></i>
</div>
<small data-bv-validator="emailAddress" data-bv-validator-for="complainant_email" class="help-block" style="display: none;">Please enter a valid email address or leave it blank</small><small data-bv-validator="notEmpty"
data-bv-validator-for="complainant_email" class="help-block" style="display: none;">Please enter a valid email address or leave it blank</small><small data-bv-validator="stringLength" data-bv-validator-for="complainant_email"
class="help-block" style="display: none;">This value is not valid</small>
</div>
<div class="form-group">
<label>What is the best way to contact you?</label>
<div class="input-group">
<label class="radio-inline"><input type="radio" id="complainant_contact_method" name="complainant_contact_method" value="Primary Phone">Primary Phone</label>
<label class="radio-inline"><input type="radio" id="complainant_contact_method" name="complainant_contact_method" value="Secondary Phone">Secondary Phone</label>
<label class="radio-inline"><input type="radio" id="complainant_contact_method" name="complainant_contact_method" value="Email">Email</label>
</div>
</div>
</div>
</div>
</div> <!-- end of panel body -->
</div> <!-- end of panel -->
<!-- END of complaint information------------------------------------------------------------------------------------------------------------------------>
<!-- END of complaint information------------------------------------------------------------------------------------------------------------------------>
<!-- START of subject information ---------------------------------------------------------------------------------------------------------------------->
<!-- START of subject information ---------------------------------------------------------------------------------------------------------------------->
<div class="panel panel-default">
<div class="panel-heading">SUBJECT OF YOUR COMPLAINT</div>
<div class="panel-body">
<div>
<p id="subjectOfC">Please enter as much information as you can regarding the primary person or company allegedly involved in the complaint.</p>
</div>
<div class="form-group">
<label>The subject is a: </label>
<div>
<label class="radio-inline"><input type="radio" id="subject_is" name="subject_is" value="Person">Person</label>
<label class="radio-inline"><input type="radio" id="subject_is" name="subject_is" value="Company">Company</label>
<label class="radio-inline"><input type="radio" id="subject_is" name="subject_is" value="Unknown">Unknown</label>
</div>
</div>
<div class="form-group has-feedback">
<label for="subject_first_name"><span class="fieldRequired" id="subject_first_name_required_label">*</span>First Name</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-user"></i></span>
<input type="text" class="form-control" id="subject_first_name" name="subject_first_name" placeholder="Enter subject first name or type 'unknown'" maxlength="50"
data-bv-field="subject_first_name"><i class="form-control-feedback" data-bv-icon-for="subject_first_name" style="display: none;"></i>
</div>
<small data-bv-validator="notEmpty" data-bv-validator-for="subject_first_name" class="help-block" style="display: none;">Please enter subject first name or type 'unknown'</small><small data-bv-validator="stringLength"
data-bv-validator-for="subject_first_name" class="help-block" style="display: none;">This value is not valid</small>
</div>
<div class="form-group has-feedback">
<label for="subject_last_name"><span class="fieldRequired" id="subject_last_name_required_label">*</span>Last Name</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-user"></i></span>
<input type="text" class="form-control" id="subject_last_name" name="subject_last_name" placeholder="Enter subject last name or type 'unknown'" maxlength="50"
data-bv-field="subject_last_name"><i class="form-control-feedback" data-bv-icon-for="subject_last_name" style="display: none;"></i>
</div>
<small data-bv-validator="notEmpty" data-bv-validator-for="subject_last_name" class="help-block" style="display: none;">Please enter subject last name or type 'unknown'</small><small data-bv-validator="stringLength"
data-bv-validator-for="subject_last_name" class="help-block" style="display: none;">This value is not valid</small>
</div>
<div class="form-group has-feedback">
<label for="subject_nickname">Nickname</label>
<div class="input-group "> <span class="input-group-addon"><i class="glyphicon glyphicon-user"></i></span>
<input type="text" class="form-control" name="subject_nickname" id="subject_nickname" placeholder="Enter subject nickname" maxlength="50"
data-bv-field="subject_nickname"><i class="form-control-feedback" data-bv-icon-for="subject_nickname" style="display: none;"></i>
</div>
<small data-bv-validator="stringLength" data-bv-validator-for="subject_nickname" class="help-block" style="display: none;">This value is not valid</small>
</div>
<!--
<div class = "form-group">
<label >Date of Birth(mm/dd/yyyy)</label>
<div class='input-group date' id="subject_dob" >
<input type='text' class="form-control" name="subject_dob" id="subject_dob_focus" />
<span class="input-group-addon"><span class="glyphicon glyphicon-calendar"></span></span>
</div>
</div>
-->
<div class="form-group">
<label>Date of Birth</label><br>
<input type="text" id="subject_dob_combo" data-format="MM/DD/YYYY" data-template="MM DD YYYY" name="subject_dob_combo" style="display: none;"><span class="combodate"><select class="month " style="width: auto;">
<option value=""></option>
<option value="0">01</option>
<option value="1">02</option>
<option value="2">03</option>
<option value="3">04</option>
<option value="4">05</option>
<option value="5">06</option>
<option value="6">07</option>
<option value="7">08</option>
<option value="8">09</option>
<option value="9">10</option>
<option value="10">11</option>
<option value="11">12</option>
</select> <select class="day " style="width: auto;">
<option value=""></option>
<option value="1">01</option>
<option value="2">02</option>
<option value="3">03</option>
<option value="4">04</option>
<option value="5">05</option>
<option value="6">06</option>
<option value="7">07</option>
<option value="8">08</option>
<option value="9">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
</select> <select class="year " style="width: auto;">
<option value=""></option>
<option value="2024">2024</option>
<option value="2023">2023</option>
<option value="2022">2022</option>
<option value="2021">2021</option>
<option value="2020">2020</option>
<option value="2019">2019</option>
<option value="2018">2018</option>
<option value="2017">2017</option>
<option value="2016">2016</option>
<option value="2015">2015</option>
<option value="2014">2014</option>
<option value="2013">2013</option>
<option value="2012">2012</option>
<option value="2011">2011</option>
<option value="2010">2010</option>
<option value="2009">2009</option>
<option value="2008">2008</option>
<option value="2007">2007</option>
<option value="2006">2006</option>
<option value="2005">2005</option>
<option value="2004">2004</option>
<option value="2003">2003</option>
<option value="2002">2002</option>
<option value="2001">2001</option>
<option value="2000">2000</option>
<option value="1999">1999</option>
<option value="1998">1998</option>
<option value="1997">1997</option>
<option value="1996">1996</option>
<option value="1995">1995</option>
<option value="1994">1994</option>
<option value="1993">1993</option>
<option value="1992">1992</option>
<option value="1991">1991</option>
<option value="1990">1990</option>
<option value="1989">1989</option>
<option value="1988">1988</option>
<option value="1987">1987</option>
<option value="1986">1986</option>
<option value="1985">1985</option>
<option value="1984">1984</option>
<option value="1983">1983</option>
<option value="1982">1982</option>
<option value="1981">1981</option>
<option value="1980">1980</option>
<option value="1979">1979</option>
<option value="1978">1978</option>
<option value="1977">1977</option>
<option value="1976">1976</option>
<option value="1975">1975</option>
<option value="1974">1974</option>
<option value="1973">1973</option>
<option value="1972">1972</option>
<option value="1971">1971</option>
<option value="1970">1970</option>
<option value="1969">1969</option>
<option value="1968">1968</option>
<option value="1967">1967</option>
<option value="1966">1966</option>
<option value="1965">1965</option>
<option value="1964">1964</option>
<option value="1963">1963</option>
<option value="1962">1962</option>
<option value="1961">1961</option>
<option value="1960">1960</option>
<option value="1959">1959</option>
<option value="1958">1958</option>
<option value="1957">1957</option>
<option value="1956">1956</option>
<option value="1955">1955</option>
<option value="1954">1954</option>
<option value="1953">1953</option>
<option value="1952">1952</option>
<option value="1951">1951</option>
<option value="1950">1950</option>
<option value="1949">1949</option>
<option value="1948">1948</option>
<option value="1947">1947</option>
<option value="1946">1946</option>
<option value="1945">1945</option>
<option value="1944">1944</option>
<option value="1943">1943</option>
<option value="1942">1942</option>
<option value="1941">1941</option>
<option value="1940">1940</option>
<option value="1939">1939</option>
<option value="1938">1938</option>
<option value="1937">1937</option>
<option value="1936">1936</option>
<option value="1935">1935</option>
<option value="1934">1934</option>
<option value="1933">1933</option>
<option value="1932">1932</option>
<option value="1931">1931</option>
<option value="1930">1930</option>
<option value="1929">1929</option>
<option value="1928">1928</option>
<option value="1927">1927</option>
<option value="1926">1926</option>
<option value="1925">1925</option>
<option value="1924">1924</option>
<option value="1923">1923</option>
<option value="1922">1922</option>
<option value="1921">1921</option>
<option value="1920">1920</option>
<option value="1919">1919</option>
<option value="1918">1918</option>
<option value="1917">1917</option>
<option value="1916">1916</option>
<option value="1915">1915</option>
<option value="1914">1914</option>
<option value="1913">1913</option>
<option value="1912">1912</option>
<option value="1911">1911</option>
<option value="1910">1910</option>
<option value="1909">1909</option>
<option value="1908">1908</option>
<option value="1907">1907</option>
<option value="1906">1906</option>
<option value="1905">1905</option>
<option value="1904">1904</option>
<option value="1903">1903</option>
<option value="1902">1902</option>
<option value="1901">1901</option>
<option value="1900">1900</option>
</select></span>
</div>
<div class="form-group has-feedback">
<label><span class="fieldRequired" id="subject_is_city_employee_required_label">*</span>Is the subject a City Employee?</label>
<div class="radio"><label><input type="radio" id="subject_is_city_employee" name="subject_is_city_employee" value="Yes" data-bv-field="subject_is_city_employee"> Yes</label></div>
<div class="radio"><label><input type="radio" id="subject_is_city_employee" name="subject_is_city_employee" value="No" data-bv-field="subject_is_city_employee"> No</label></div>
<div class="radio"><label><input type="radio" id="subject_is_city_employee" name="subject_is_city_employee" value="Unknown"
data-bv-field="subject_is_city_employee"><i class="form-control-feedback" data-bv-icon-for="subject_is_city_employee" style="display: none;"></i> Unknown</label></div>
<small data-bv-validator="notEmpty" data-bv-validator-for="subject_is_city_employee" class="help-block" style="display: none;">Please select an option</small>
</div>
<div id="subject_city_agency_show_hide" style="display:none;">
<div class="well">
<div class="form-group">
<label>Select City Agency</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-list"></i></span>
<select class="form-control" id="subject_city_agency" name="subject_city_agency">
<option value="" selected="" disabled="">Choose a City Agency </option>
<option value="Administration for Children Services (ACS)">Administration for Children Services (ACS)</option>
<option value="Board of Election (BOE)">Board of Election (BOE)</option>
<option value="Board of Estimate (BDEST)">Board of Estimate (BDEST)</option>
<option value="Board of Standards and Appeals (BSA)">Board of Standards and Appeals (BSA)</option>
<option value="Borough President – Bronx">Borough President – Bronx</option>
<option value="Borough President – Brooklyn">Borough President – Brooklyn</option>
<option value="Borough President – Manhattan">Borough President – Manhattan</option>
<option value="Borough President – Queens">Borough President – Queens</option>
<option value="Borough President – Staten Island">Borough President – Staten Island</option>
<option value="Business Integrity Commission (BIC)">Business Integrity Commission (BIC)</option>
<option value="Campaign Finance Board (CFB)">Campaign Finance Board (CFB)</option>
<option value="City Clerk's Office">City Clerk's Office</option>
<option value="City Council">City Council</option>
<option value="City Marshal">City Marshal</option>
<option value="City Sheriff (Sheriff)">City Sheriff (Sheriff) </option>
<option value="City University of New York (CUNY)">City University of New York (CUNY)</option>
<option value="Civil Service Commission (CSC)">Civil Service Commission (CSC)</option>
<option value="Civilian Complaint Review Board (CCRB)">Civilian Complaint Review Board (CCRB)</option>
<option value="Commission on Human Rights (CCHR)">Commission on Human Rights (CCHR)</option>
<option value="Community Board – Manhattan">Community Board – Manhattan</option>
<option value="Community Board – Brooklyn">Community Board – Brooklyn</option>
<option value="Community Board – Bronx">Community Board – Bronx</option>
<option value="Community Board – Queens">Community Board – Queens</option>
<option value="Community Board – Staten Island">Community Board – Staten Island</option>
<option value="Conflicts of Interest Board (COIB)">Conflicts of Interest Board (COIB)</option>
<option value="Department for the Aging (DFTA)">Department for the Aging (DFTA)</option>
<option value="Department of Buildings (DOB)">Department of Buildings (DOB)</option>
<option value="Department of City Planning (DCP)">Department of City Planning (DCP)</option>
<option value="Department of Citywide Administrative Services (DCAS)">Department of Citywide Administrative Services (DCAS)</option>
<option value="Department of Consumer Affairs (DCA)">Department of Consumer Affairs (DCA)</option>
<option value="Department of Correction (DOC)">Department of Correction (DOC)</option>
<option value="Department of Cultural Affairs (DCLA)">Department of Cultural Affairs (DCLA)</option>
<option value="Department of Design & Construction (DDC)">Department of Design & Construction (DDC)</option>
<option value="Department of Education (DOE)">Department of Education (DOE)</option>
<option value="Department of Environmental Protection (DEP)">Department of Environmental Protection (DEP)</option>
<option value="Department of Finance (DOF)">Department of Finance (DOF)</option>
<option value="Department of Health & Mental Hygiene (DOHMH)">Department of Health & Mental Hygiene (DOHMH)</option>
<option value="Department of Homeless Services (DHS)">Department of Homeless Services (DHS)</option>
<option value="Department of Housing Preservation & Development (HPD)">Department of Housing Preservation & Development (HPD)</option>
<option value="Department of Information Technology & Telecommunications (DoITT)">Department of Information Technology & Telecommunications (DoITT)</option>
<option value="Department of Investigation (DOI)">Department of Investigation (DOI)</option>
<option value="Department of Parks & Recreation (Parks)">Department of Parks & Recreation (Parks)</option>
<option value="Department of Probation (DOP)">Department of Probation (DOP)</option>
<option value="Department of Records & Information Services (DORIS)">Department of Records & Information Services (DORIS)</option>
<option value="Department of Sanitation (DSNY)">Department of Sanitation (DSNY)</option>
<option value="Department of Small Business Services (SBS)">Department of Small Business Services (SBS)</option>
<option value="Department of Transportation (DOT)">Department of Transportation (DOT)</option>
<option value="Department of Youth & Community Development (DYCD)">Department of Youth & Community Development (DYCD)</option>
<option value="Department of Youth & Family Justice (DYFJ)">Department of Youth & Family Justice (DYFJ)</option>
<option value="District Attorney – Manhattan (NYDA)">District Attorney – Manhattan (NYDA)</option>
<option value="District Attorney – Brooklyn (BKDA)">District Attorney – Brooklyn (BKDA)</option>
<option value="District Attorney – Queens (QNDA)">District Attorney – Queens (QNDA)</option>
<option value="District Attorney – Bronx (BXDA)">District Attorney – Bronx (BXDA)</option>
<option value="District Attorney – Richmond (SIDA)">District Attorney – Richmond (SIDA)</option>
<option value="Economic Development Corporation (EDC)">Economic Development Corporation (EDC)</option>
<option value="Emergency Medical Services (EMS)">Emergency Medical Services (EMS)</option>
<option value="Financial Information Services Agency (FISA)">Financial Information Services Agency (FISA)</option>
<option value="Fire Department (FDNY)">Fire Department (FDNY)</option>
<option value="Health and Hospitals Corporation (HHC)">Health and Hospitals Corporation (HHC)</option>
<option value="Human Resources Administration (HRA)">Human Resources Administration (HRA)</option>
<option value="Human Rights Commission (HRC)">Human Rights Commission (HRC)</option>
<option value="Independent Budget Office (IBO)">Independent Budget Office (IBO)</option>
<option value="Landmarks Preservation Commission (LPC) ">Landmarks Preservation Commission (LPC) </option>
<option value="Law Department (LAW)">Law Department (LAW)</option>
<option value="Mayor's Office">Mayor's Office </option>
<option value="New York City Comptroller's Office">New York City Comptroller's Office</option>
<option value="New York City Housing Authority (NYCHA)">New York City Housing Authority (NYCHA)</option>
<option value="New York City Employees Retirement System (NYCERS)">New York City Employees Retirement System (NYCERS)</option>
<option value="New York City School Construction Authority (SCA)">New York City School Construction Authority (SCA)</option>
<option value="Office of the Actuary (NYCOA)">Office of the Actuary (NYCOA)</option>
<option value="Office of Administrative Trials and Hearings (OATH)">Office of Administrative Trials and Hearings (OATH)</option>
<option value="Office of Chief Medical Examiner (OCME)">Office of Chief Medical Examiner (OCME)</option>
<option value="Office of Collective Bargaining (OCB)">Office of Collective Bargaining (OCB)</option>
<option value="Office of Management & Budget (OMB)">Office of Management & Budget (OMB)</option>
<option value="Office of the Mayor (MAYOR)">Office of the Mayor (MAYOR)</option>
<option value="Office of Payroll Management (OPA)">Office of Payroll Management (OPA)</option>
<option value="Police Department (NYPD)">Police Department (NYPD)</option>
<option value="Procurement Policy Board (PPB)">Procurement Policy Board (PPB)</option>
<option value="Public Administrator – New York (PANY)">Public Administrator – New York (PANY)</option>
<option value="Public Administrator – Bronx (PABX)">Public Administrator – Bronx (PABX)</option>
<option value="Public Administrator – Brooklyn (PABK)">Public Administrator – Brooklyn (PABK)</option>
<option value="Public Administrator – Queens (PAQN)">Public Administrator – Queens (PAQN)</option>
<option value="Public Administrator – Richmond (PASI)">Public Administrator – Richmond (PASI)</option>
<option value="Public Advocate – (PUBADV)">Public Advocate – (PUBADV)</option>
<option value="Rent Guidelines Board (RGB)">Rent Guidelines Board (RGB)</option>
<option value="Tax Appeals Tribunal">Tax Appeals Tribunal</option>
<option value="Tax Commission (TC)">Tax Commission (TC)</option>
<option value="Taxi & Limousine Commission (TLC)">Taxi & Limousine Commission (TLC)</option>
</select>
</div>
</div>
<div class="form-group">
<label for="subject_title">Title (Include Rank and Shield Number if Applicable)</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-question-sign"></i></span>
<input type="text" class="form-control" id="subject_title" name="subject_title" placeholder="Enter subject title" maxlength="75">
</div>
</div>
</div> <!-- well -->
</div> <!-- end of subject_city_agency_show_hide -->
<div class="form-group has-feedback">
<label><span class="fieldRequired" id="subject_company_name_required_label">*</span>Company Name</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-tower"></i></span>
<input type="text" class="form-control" id="subject_company_name" name="subject_company_name" placeholder="Enter company name" maxlength="75"
data-bv-field="subject_company_name"><i class="form-control-feedback" data-bv-icon-for="subject_company_name" style="display: none;"></i>
</div>
<small data-bv-validator="notEmpty" data-bv-validator-for="subject_company_name" class="help-block" style="display: none;">Please enter company name</small><small data-bv-validator="stringLength" data-bv-validator-for="subject_company_name"
class="help-block" style="display: none;">This value is not valid</small>
</div>
<div class="form-group has-feedback">
<label>EIN</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-tower"></i></span>
<input type="text" class="form-control" id="subject_ein" name="subject_ein" placeholder="Enter EIN(number only)" maxlength="15"
data-bv-field="subject_ein"><i class="form-control-feedback" data-bv-icon-for="subject_ein" style="display: none;"></i>
</div>
<small data-bv-validator="stringLength" data-bv-validator-for="subject_ein" class="help-block" style="display: none;">This value is not valid</small>
</div>
<div class="form-group has-feedback">
<label><span class="fieldRequired">*</span>Subject Address:</label>
<div class="radio"><label><input type="radio" name="subject_address_type" value="Home" data-bv-field="subject_address_type"> Home</label></div>
<div class="radio"><label><input type="radio" name="subject_address_type" value="Business" data-bv-field="subject_address_type"> Business</label></div>
<div class="radio"><label><input type="radio" name="subject_address_type" value="Unknown" data-bv-field="subject_address_type"><i class="form-control-feedback" data-bv-icon-for="subject_address_type" style="display: none;"></i>
Unknown</label></div>
<small data-bv-validator="notEmpty" data-bv-validator-for="subject_address_type" class="help-block" style="display: none;">Please select an option</small>
</div>
<div class="form-group has-feedback">
<label for="subject_street_address">Street Address</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-home"></i></span>
<input type="text" class="form-control" id="subject_street_address" name="subject_street_address" placeholder="Enter subject street address" maxlength="50"
data-bv-field="subject_street_address"><i class="form-control-feedback" data-bv-icon-for="subject_street_address" style="display: none;"></i>
</div>
<small data-bv-validator="stringLength" data-bv-validator-for="subject_street_address" class="help-block" style="display: none;">This value is not valid</small>
</div>
<div class="form-group has-feedback">
<label for="subject_apt_number">Apt#/Room/Floor/Suite</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-home"></i></span>
<input type="text" class="form-control" id="subject_apt_number" name="subject_apt_number" placeholder="Enter subject Apt#/Room/Floor/Suite" maxlength="75"
data-bv-field="subject_apt_number"><i class="form-control-feedback" data-bv-icon-for="subject_apt_number" style="display: none;"></i>
</div>
<small data-bv-validator="stringLength" data-bv-validator-for="subject_apt_number" class="help-block" style="display: none;">This value is not valid</small>
</div>
<div class="form-group has-feedback">
<label for="subject_city_town">City</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-home"></i></span>
<input type="text" class="form-control" id="subject_city_town" name="subject_city_town" placeholder="Enter subject City" maxlength="50"
data-bv-field="subject_city_town"><i class="form-control-feedback" data-bv-icon-for="subject_city_town" style="display: none;"></i>
</div>
<small data-bv-validator="stringLength" data-bv-validator-for="subject_city_town" class="help-block" style="display: none;">This value is not valid</small>
</div>
<div class="form-group">
<label for="subject_state">State</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-list"></i></span>
<select class="form-control" id="subject_state" name="subject_state">
<option value="" selected="" disabled="">Choose a State </option>
<option value="Alabama">Alabama</option>
<option value="Alaska">Alaska</option>
<option value="Arizona">Arizona</option>
<option value="Arkansas">Arkansas</option>
<option value="California">California</option>
<option value="Colorado">Colorado</option>
<option value="Connecticut">Connecticut</option>
<option value="Delaware">Delaware</option>
<option value="District of Columbia">District of Columbia</option>
<option value="Florida">Florida</option>
<option value="Georgia">Georgia</option>
<option value="Hawaii">Hawaii</option>
<option value="Idaho">Idaho</option>
<option value="Illinois">Illinois</option>
<option value="Indiana">Indiana</option>
<option value="Iowa">Iowa</option>
<option value="Kansas">Kansas</option>
<option value="Kentucky">Kentucky</option>
<option value="Louisiana">Louisiana</option>
<option value="Maine">Maine</option>
<option value="Maryland">Maryland</option>
<option value="Massachusetts">Massachusetts</option>
<option value="Michigan">Michigan</option>
<option value="Minnesota">Minnesota</option>
<option value="Mississippi">Mississippi</option>
<option value="Missouri">Missouri</option>
<option value="Montana">Montana</option>
<option value="Nebraska">Nebraska</option>
<option value="Nevada">Nevada</option>
<option value="New Hampshire">New Hampshire</option>
<option value="New Jersey">New Jersey</option>
<option value="New Mexico">New Mexico</option>
<option value="New York">New York</option>
<option value="North Carolina">North Carolina</option>
<option value="North Dakota">North Dakota</option>
<option value="Ohio">Ohio</option>
<option value="Oklahoma">Oklahoma</option>
<option value="Oregon">Oregon</option>
<option value="Pennsylvania">Pennsylvania</option>
<option value="Rhode Island">Rhode Island</option>
<option value="South Carolina">South Carolina</option>
<option value="South Dakota">South Dakota</option>
<option value="Tennessee">Tennessee</option>
<option value="Texas">Texas</option>
<option value="Utah">Utah</option>
<option value="Vermont">Vermont</option>
<option value="Virginia">Virginia</option>
<option value="Washington">Washington</option>
<option value="West Virginia">West Virginia</option>
<option value="Wisconsin">Wisconsin</option>
<option value="Wyoming">Wyoming</option>
</select>
</div>
</div>
<div class="form-group has-feedback">
<label for="subject_zip">Zip Code</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-home"></i></span>
<input type="text" class="form-control" id="subject_zip_code" name="subject_zip_code" placeholder="Enter subject zip code" maxlength="5"
data-bv-field="subject_zip_code"><i class="form-control-feedback" data-bv-icon-for="subject_zip_code" style="display: none;"></i>
</div>
<small data-bv-validator="zipCode" data-bv-validator-for="subject_zip_code" class="help-block" style="display: none;">Please enter a valid zip code or leave it blank</small><small data-bv-validator="stringLength"
data-bv-validator-for="subject_zip_code" class="help-block" style="display: none;">This value is not valid</small>
</div>
<div class="form-group has-feedback">
<label>Primary Phone</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-phone"></i></span>
<input type="text" class="form-control input-medium bfh-phone" data-format=" (ddd) ddd-dddd" id="subject_primary_phone" name="subject_primary_phone" maxlength="15"
data-bv-field="subject_primary_phone"><i class="form-control-feedback" data-bv-icon-for="subject_primary_phone" style="display: none;"></i>
</div>
<small data-bv-validator="stringLength" data-bv-validator-for="subject_primary_phone" class="help-block" style="display: none;">This value is not valid</small>
</div>
<div class="form-group has-feedback">
<label>Secondary Phone</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-phone"></i></span>
<input type="text" class="form-control input-medium bfh-phone" data-format=" (ddd) ddd-dddd" id="subject_secondary_phone" name="subject_secondary_phone" maxlength="15"
data-bv-field="subject_secondary_phone"><i class="form-control-feedback" data-bv-icon-for="subject_secondary_phone" style="display: none;"></i>
</div>
<small data-bv-validator="stringLength" data-bv-validator-for="subject_secondary_phone" class="help-block" style="display: none;">This value is not valid</small>
</div>
<div class="form-group has-feedback">
<label for="subject_website">Website</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-globe"></i></span>
<input type="text" class="form-control" id="subject_website" name="subject_website" placeholder="Enter subject website" maxlength="300"
data-bv-field="subject_website"><i class="form-control-feedback" data-bv-icon-for="subject_website" style="display: none;"></i>
</div>
<small data-bv-validator="uri" data-bv-validator-for="subject_website" class="help-block" style="display: none;">The website address is not valid</small><small data-bv-validator="stringLength" data-bv-validator-for="subject_website"
class="help-block" style="display: none;">This value is not valid</small>
</div>
<div class="form-group has-feedback">
<label for="subject_email">Email Address</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-envelope"></i></span>
<input type="text" class="form-control" id="subject_email" name="subject_email" placeholder="Enter subject email address" maxlength="75"
data-bv-field="subject_email"><i class="form-control-feedback" data-bv-icon-for="subject_email" style="display: none;"></i>
</div>
<small data-bv-validator="emailAddress" data-bv-validator-for="subject_email" class="help-block" style="display: none;">Please enter a valid email address or leave it blank</small><small data-bv-validator="stringLength"
data-bv-validator-for="subject_email" class="help-block" style="display: none;">This value is not valid</small>
</div>
<div class="well">
<div class="form-group">
<label>Are there any additional addresses involved in this complaint?</label>
<div class="radio"><label><input type="radio" id="subject_additional_address_involved" name="subject_additional_address_involved" value="Yes">Yes</label></div>
<div class="radio"><label><input type="radio" id="subject_additional_address_involved" name="subject_additional_address_involved" value="No">No</label></div>
</div>
<!-- additional address start -->
<div id="subject_additional_address_show_hide" style="display:none;">
<div class="form-group has-feedback">
<label><span class="fieldRequired">*</span>Subject Address:</label>
<div class="radio"><label><input type="radio" name="subject_address2_type" value="Home" data-bv-field="subject_address2_type"> Home</label></div>
<div class="radio"><label><input type="radio" name="subject_address2_type" value="Business" data-bv-field="subject_address2_type"> Business</label></div>
<div class="radio"><label><input type="radio" name="subject_address2_type" value="Unknown" data-bv-field="subject_address2_type"><i class="form-control-feedback" data-bv-icon-for="subject_address2_type" style="display: none;"></i>
Unknown</label></div>
<small data-bv-validator="notEmpty" data-bv-validator-for="subject_address2_type" class="help-block" style="display: none;">Please select an option</small>
</div>
<div class="form-group">
<label for="subject_street_address2">Street Address</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-home"></i></span>
<input type="text" class="form-control" id="subject_street_address2" name="subject_street_address2" placeholder="Enter subject street address" maxlength="50">
</div>
</div>
<div class="form-group">
<label for="subject_apt_number2">Apt#/Room/Floor/Suite</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-home"></i></span>
<input type="text" class="form-control" id="subject_apt_number2" name="subject_apt_number2" placeholder="Enter subject Apt#/Room/Floor/Suite" maxlength="75">
</div>
</div>
<div class="form-group">
<label for="subject_city_town2">City</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-home"></i></span>
<input type="text" class="form-control" id="subject_city_town2" name="subject_city_town2" placeholder="Enter subject City" maxlength="50">
</div>
</div>
<div class="form-group">
<label for="subject_state2">State</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-list"></i></span>
<select class="form-control" id="subject_state2" name="subject_state">
<option value="" selected="" disabled="">Choose a State </option>
<option value="Alabama">Alabama</option>
<option value="Alaska">Alaska</option>
<option value="Arizona">Arizona</option>
<option value="Arkansas">Arkansas</option>
<option value="California">California</option>
<option value="Colorado">Colorado</option>
<option value="Connecticut">Connecticut</option>
<option value="Delaware">Delaware</option>
<option value="District of Columbia">District of Columbia</option>
<option value="Florida">Florida</option>
<option value="Georgia">Georgia</option>
<option value="Hawaii">Hawaii</option>
<option value="Idaho">Idaho</option>
<option value="Illinois">Illinois</option>
<option value="Indiana">Indiana</option>
<option value="Iowa">Iowa</option>
<option value="Kansas">Kansas</option>
<option value="Kentucky">Kentucky</option>
<option value="Louisiana">Louisiana</option>
<option value="Maine">Maine</option>
<option value="Maryland">Maryland</option>
<option value="Massachusetts">Massachusetts</option>
<option value="Michigan">Michigan</option>
<option value="Minnesota">Minnesota</option>
<option value="Mississippi">Mississippi</option>
<option value="Missouri">Missouri</option>
<option value="Montana">Montana</option>
<option value="Nebraska">Nebraska</option>
<option value="Nevada">Nevada</option>
<option value="New Hampshire">New Hampshire</option>
<option value="New Jersey">New Jersey</option>
<option value="New Mexico">New Mexico</option>
<option value="New York">New York</option>
<option value="North Carolina">North Carolina</option>
<option value="North Dakota">North Dakota</option>
<option value="Ohio">Ohio</option>
<option value="Oklahoma">Oklahoma</option>
<option value="Oregon">Oregon</option>
<option value="Pennsylvania">Pennsylvania</option>
<option value="Rhode Island">Rhode Island</option>
<option value="South Carolina">South Carolina</option>
<option value="South Dakota">South Dakota</option>
<option value="Tennessee">Tennessee</option>
<option value="Texas">Texas</option>
<option value="Utah">Utah</option>
<option value="Vermont">Vermont</option>
<option value="Virginia">Virginia</option>
<option value="Washington">Washington</option>
<option value="West Virginia">West Virginia</option>
<option value="Wisconsin">Wisconsin</option>
<option value="Wyoming">Wyoming</option>
</select>
</div>
</div>
<div class="form-group has-feedback">
<label for="subject_zip_code2">Zip Code</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-home"></i></span>
<input type="text" class="form-control" id="subject_zip_code2" name="subject_zip_code2" placeholder="Enter subject zip code" maxlength="5"
data-bv-field="subject_zip_code2"><i class="form-control-feedback" data-bv-icon-for="subject_zip_code2" style="display: none;"></i>
</div>
<small data-bv-validator="zipCode" data-bv-validator-for="subject_zip_code2" class="help-block" style="display: none;">Please enter a valid zip code or leave it blank</small>
</div>
<div class="form-group">
<label>Primary Phone</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-phone"></i></span>
<input type="text" class="form-control input-medium bfh-phone" data-format=" (ddd) ddd-dddd" id="subject_primary_phone2" name="subject_primary_phone2" maxlength="15">
</div>
</div>
<div class="form-group">
<label>Secondary Phone</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-phone"></i></span>
<input type="text" class="form-control input-medium bfh-phone" data-format=" (ddd) ddd-dddd" id="subject_secondary_phone2" name="subject_secondary_phone2" maxlength="15">
</div>
</div>
<div class="form-group has-feedback">
<label for="subject_website2">Website</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-globe"></i></span>
<input type="text" class="form-control" id="subject_website2" name="subject_website2" placeholder="Enter subject website" maxlength="300"
data-bv-field="subject_website2"><i class="form-control-feedback" data-bv-icon-for="subject_website2" style="display: none;"></i>
</div>
<small data-bv-validator="uri" data-bv-validator-for="subject_website2" class="help-block" style="display: none;">The website address is not valid</small>
</div>
<div class="form-group has-feedback">
<label for="subject_email2">Email Address</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-envelope"></i></span>
<input type="text" class="form-control" id="subject_email2" name="subject_email2" placeholder="Enter subject email address" maxlength="75"
data-bv-field="subject_email2"><i class="form-control-feedback" data-bv-icon-for="subject_email2" style="display: none;"></i>
</div>
<small data-bv-validator="emailAddress" data-bv-validator-for="subject_email2" class="help-block" style="display: none;">Please enter a valid email address or leave it blank</small>
</div>
</div> <!-- well_rb -->
</div> <!-- end of 'subject_additional_address_show_hide' -->
<!-- additional address end -->
<!-- END of PRIMARY subject information ---------------------------------------------------------------------------------------------------------------------->
<div class="well">
<div class="form-group has-feedback">
<label><span class="fieldRequired" id="subject_additional_subject_involved_label">*</span>Are there any additional subjects involved in this complaint?</label>
<div class="radio"><label><input type="radio" id="subject_additional_subject_involved" name="subject_additional_subject_involved" value="Yes" data-bv-field="subject_additional_subject_involved">Yes</label></div>
<div class="radio"><label><input type="radio" id="subject_additional_subject_involved" name="subject_additional_subject_involved" value="No"
data-bv-field="subject_additional_subject_involved"><i class="form-control-feedback" data-bv-icon-for="subject_additional_subject_involved" style="display: none;"></i>No</label></div>
<small data-bv-validator="notEmpty" data-bv-validator-for="subject_additional_subject_involved" class="help-block" style="display: none;">Please select an option</small>
</div>
<!-- START of additional subject information --------------------------------------------------------------------------------------------------------->
<!-- START of additional subject information --------------------------------------------------------------------------------------------------------->
<div id="additional_subject_show_hide" style="display:none;">
<div class="form-group">
<label>The subject is a: </label>
<div>
<label class="radio-inline"><input type="radio" id="subject2_is" name="subject2_is" value="Person">Person</label>
<label class="radio-inline"><input type="radio" id="subject2_is" name="subject2_is" value="Company">Company</label>
<label class="radio-inline"><input type="radio" id="subject2_is" name="subject2_is" value="Unknown">Unknown</label>
</div>
</div>
<div class="form-group has-feedback">
<label><span class="fieldRequired" id="subject2_first_name_required_label">*</span>First Name</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-user"></i></span>
<input type="text" class="form-control" id="subject2_first_name" name="subject2_first_name" placeholder="Enter subject first name or type 'unknown'" maxlength="50"
data-bv-field="subject2_first_name"><i class="form-control-feedback" data-bv-icon-for="subject2_first_name" style="display: none;"></i>
</div>
<small data-bv-validator="notEmpty" data-bv-validator-for="subject2_first_name" class="help-block" style="display: none;">Please enter subject first name or type 'unknown'</small>
</div>
<div class="form-group has-feedback">
<label><span class="fieldRequired" id="subject2_last_name_required_label">*</span>Last Name</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-user"></i></span>
<input type="text" class="form-control" id="subject2_last_name" name="subject2_last_name" placeholder="Enter subject last name or type 'unknown'" maxlength="50"
data-bv-field="subject2_last_name"><i class="form-control-feedback" data-bv-icon-for="subject2_last_name" style="display: none;"></i>
</div>
<small data-bv-validator="notEmpty" data-bv-validator-for="subject2_last_name" class="help-block" style="display: none;">Please enter subject last name or type 'unknown'</small>
</div>
<div class="form-group">
<label for="subject2_nickname">Nickname</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-user"></i></span>
<input type="text" class="form-control" id="subject2_nickname" name="subject2_nickname" placeholder="Enter subject nickname" maxlength="50">
</div>
</div>
<!--
<div class = "form-group">
<label >Date of Birth(mm/dd/yyyy)</label>
<div class='input-group date' id="subject2_dob" >
<input type='text' class="form-control" name="subject2_dob" id="subject2_dob_focus" />
<span class="input-group-addon"><span class="glyphicon glyphicon-calendar"></span></span>
</div>
</div>
-->
<div class="form-group">
<label>Date of Birth</label><br>
<input type="text" id="subject2_dob_combo" data-format="MM/DD/YYYY" data-template="MM DD YYYY" name="subject2_dob_combo" style="display: none;"><span class="combodate"><select class="month " style="width: auto;">
<option value=""></option>
<option value="0">01</option>
<option value="1">02</option>
<option value="2">03</option>
<option value="3">04</option>
<option value="4">05</option>
<option value="5">06</option>
<option value="6">07</option>
<option value="7">08</option>
<option value="8">09</option>
<option value="9">10</option>
<option value="10">11</option>
<option value="11">12</option>
</select> <select class="day " style="width: auto;">
<option value=""></option>
<option value="1">01</option>
<option value="2">02</option>
<option value="3">03</option>
<option value="4">04</option>
<option value="5">05</option>
<option value="6">06</option>
<option value="7">07</option>
<option value="8">08</option>
<option value="9">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
</select> <select class="year " style="width: auto;">
<option value=""></option>
<option value="2024">2024</option>
<option value="2023">2023</option>
<option value="2022">2022</option>
<option value="2021">2021</option>
<option value="2020">2020</option>
<option value="2019">2019</option>
<option value="2018">2018</option>
<option value="2017">2017</option>
<option value="2016">2016</option>
<option value="2015">2015</option>
<option value="2014">2014</option>
<option value="2013">2013</option>
<option value="2012">2012</option>
<option value="2011">2011</option>
<option value="2010">2010</option>
<option value="2009">2009</option>
<option value="2008">2008</option>
<option value="2007">2007</option>
<option value="2006">2006</option>
<option value="2005">2005</option>
<option value="2004">2004</option>
<option value="2003">2003</option>
<option value="2002">2002</option>
<option value="2001">2001</option>
<option value="2000">2000</option>
<option value="1999">1999</option>
<option value="1998">1998</option>
<option value="1997">1997</option>
<option value="1996">1996</option>
<option value="1995">1995</option>
<option value="1994">1994</option>
<option value="1993">1993</option>
<option value="1992">1992</option>
<option value="1991">1991</option>
<option value="1990">1990</option>
<option value="1989">1989</option>
<option value="1988">1988</option>
<option value="1987">1987</option>
<option value="1986">1986</option>
<option value="1985">1985</option>
<option value="1984">1984</option>
<option value="1983">1983</option>
<option value="1982">1982</option>
<option value="1981">1981</option>
<option value="1980">1980</option>
<option value="1979">1979</option>
<option value="1978">1978</option>
<option value="1977">1977</option>
<option value="1976">1976</option>
<option value="1975">1975</option>
<option value="1974">1974</option>
<option value="1973">1973</option>
<option value="1972">1972</option>
<option value="1971">1971</option>
<option value="1970">1970</option>
<option value="1969">1969</option>
<option value="1968">1968</option>
<option value="1967">1967</option>
<option value="1966">1966</option>
<option value="1965">1965</option>
<option value="1964">1964</option>
<option value="1963">1963</option>
<option value="1962">1962</option>
<option value="1961">1961</option>
<option value="1960">1960</option>
<option value="1959">1959</option>
<option value="1958">1958</option>
<option value="1957">1957</option>
<option value="1956">1956</option>
<option value="1955">1955</option>
<option value="1954">1954</option>
<option value="1953">1953</option>
<option value="1952">1952</option>
<option value="1951">1951</option>
<option value="1950">1950</option>
<option value="1949">1949</option>
<option value="1948">1948</option>
<option value="1947">1947</option>
<option value="1946">1946</option>
<option value="1945">1945</option>
<option value="1944">1944</option>
<option value="1943">1943</option>
<option value="1942">1942</option>
<option value="1941">1941</option>
<option value="1940">1940</option>
<option value="1939">1939</option>
<option value="1938">1938</option>
<option value="1937">1937</option>
<option value="1936">1936</option>
<option value="1935">1935</option>
<option value="1934">1934</option>
<option value="1933">1933</option>
<option value="1932">1932</option>
<option value="1931">1931</option>
<option value="1930">1930</option>
<option value="1929">1929</option>
<option value="1928">1928</option>
<option value="1927">1927</option>
<option value="1926">1926</option>
<option value="1925">1925</option>
<option value="1924">1924</option>
<option value="1923">1923</option>
<option value="1922">1922</option>
<option value="1921">1921</option>
<option value="1920">1920</option>
<option value="1919">1919</option>
<option value="1918">1918</option>
<option value="1917">1917</option>
<option value="1916">1916</option>
<option value="1915">1915</option>
<option value="1914">1914</option>
<option value="1913">1913</option>
<option value="1912">1912</option>
<option value="1911">1911</option>
<option value="1910">1910</option>
<option value="1909">1909</option>
<option value="1908">1908</option>
<option value="1907">1907</option>
<option value="1906">1906</option>
<option value="1905">1905</option>
<option value="1904">1904</option>
<option value="1903">1903</option>
<option value="1902">1902</option>
<option value="1901">1901</option>
<option value="1900">1900</option>
</select></span>
</div>
<div class="form-group has-feedback">
<label><span class="fieldRequired" id="subject2_is_city_employee_required_label">*</span>Is the subject a City Employee?</label>
<div class="radio"><label><input type="radio" id="subject2_is_city_employee" name="subject2_is_city_employee" value="Yes" data-bv-field="subject2_is_city_employee"> Yes</label></div>
<div class="radio"><label><input type="radio" id="subject2_is_city_employee" name="subject2_is_city_employee" value="No" data-bv-field="subject2_is_city_employee"> No</label></div>
<div class="radio"><label><input type="radio" id="subject2_is_city_employee" name="subject2_is_city_employee" value="Unknown"
data-bv-field="subject2_is_city_employee"><i class="form-control-feedback" data-bv-icon-for="subject2_is_city_employee" style="display: none;"></i> Unknown</label></div>
<small data-bv-validator="notEmpty" data-bv-validator-for="subject2_is_city_employee" class="help-block" style="display: none;">Please select an option</small>
</div>
<div id="subject2_city_agency_show_hide" style="display:none;">
<div class="well well_rb">
<div class="form-group">
<label for="subject2_city_agency">Select Agency:</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-list"></i></span>
<select class="form-control" id="subject2_city_agency" name="subject2_city_agency">
<option value="" selected="" disabled="">Choose a City Agency </option>
<option value="Administration for Children Services (ACS)">Administration for Children Services (ACS)</option>
<option value="Board of Election (BOE)">Board of Election (BOE)</option>
<option value="Board of Estimate (BDEST)">Board of Estimate (BDEST)</option>
<option value="Board of Standards and Appeals (BSA)">Board of Standards and Appeals (BSA)</option>
<option value="Borough President – Bronx">Borough President – Bronx</option>
<option value="Borough President – Brooklyn">Borough President – Brooklyn</option>
<option value="Borough President – Manhattan">Borough President – Manhattan</option>
<option value="Borough President – Queens">Borough President – Queens</option>
<option value="Borough President – Staten Island">Borough President – Staten Island</option>
<option value="Business Integrity Commission (BIC)">Business Integrity Commission (BIC)</option>
<option value="Campaign Finance Board (CFB)">Campaign Finance Board (CFB)</option>
<option value="City Clerk's Office">City Clerk's Office</option>
<option value="City Council">City Council</option>
<option value="City Marshal">City Marshal</option>
<option value="City Sheriff (Sheriff)">City Sheriff (Sheriff) </option>
<option value="City University of New York (CUNY)">City University of New York (CUNY)</option>
<option value="Civil Service Commission (CSC)">Civil Service Commission (CSC)</option>
<option value="Civilian Complaint Review Board (CCRB)">Civilian Complaint Review Board (CCRB)</option>
<option value="Commission on Human Rights (CCHR)">Commission on Human Rights (CCHR)</option>
<option value="Community Board – Manhattan">Community Board – Manhattan</option>
<option value="Community Board – Brooklyn">Community Board – Brooklyn</option>
<option value="Community Board – Bronx">Community Board – Bronx</option>
<option value="Community Board – Queens">Community Board – Queens</option>
<option value="Community Board – Staten Island">Community Board – Staten Island</option>
<option value="Conflicts of Interest Board (COIB)">Conflicts of Interest Board (COIB)</option>
<option value="Department for the Aging (DFTA)">Department for the Aging (DFTA)</option>
<option value="Department of Buildings (DOB)">Department of Buildings (DOB)</option>
<option value="Department of City Planning (DCP)">Department of City Planning (DCP)</option>
<option value="Department of Citywide Administrative Services (DCAS)">Department of Citywide Administrative Services (DCAS)</option>
<option value="Department of Consumer Affairs (DCA)">Department of Consumer Affairs (DCA)</option>
<option value="Department of Correction (DOC)">Department of Correction (DOC)</option>
<option value="Department of Cultural Affairs (DCLA)">Department of Cultural Affairs (DCLA)</option>
<option value="Department of Design & Construction (DDC)">Department of Design & Construction (DDC)</option>
<option value="Department of Education (DOE)">Department of Education (DOE)</option>
<option value="Department of Environmental Protection (DEP)">Department of Environmental Protection (DEP)</option>
<option value="Department of Finance (DOF)">Department of Finance (DOF)</option>
<option value="Department of Health & Mental Hygiene (DOHMH)">Department of Health & Mental Hygiene (DOHMH)</option>
<option value="Department of Homeless Services (DHS)">Department of Homeless Services (DHS)</option>
<option value="Department of Housing Preservation & Development (HPD)">Department of Housing Preservation & Development (HPD)</option>
<option value="Department of Information Technology & Telecommunications (DoITT)">Department of Information Technology & Telecommunications (DoITT)</option>
<option value="Department of Investigation (DOI)">Department of Investigation (DOI)</option>
<option value="Department of Parks & Recreation (Parks)">Department of Parks & Recreation (Parks)</option>
<option value="Department of Probation (DOP)">Department of Probation (DOP)</option>
<option value="Department of Records & Information Services (DORIS)">Department of Records & Information Services (DORIS)</option>
<option value="Department of Sanitation (DSNY)">Department of Sanitation (DSNY)</option>
<option value="Department of Small Business Services (SBS)">Department of Small Business Services (SBS)</option>
<option value="Department of Transportation (DOT)">Department of Transportation (DOT)</option>
<option value="Department of Youth & Community Development (DYCD)">Department of Youth & Community Development (DYCD)</option>
<option value="Department of Youth & Family Justice (DYFJ)">Department of Youth & Family Justice (DYFJ)</option>
<option value="District Attorney – Manhattan (NYDA)">District Attorney – Manhattan (NYDA)</option>
<option value="District Attorney – Brooklyn (BKDA)">District Attorney – Brooklyn (BKDA)</option>
<option value="District Attorney – Queens (QNDA)">District Attorney – Queens (QNDA)</option>
<option value="District Attorney – Bronx (BXDA)">District Attorney – Bronx (BXDA)</option>
<option value="District Attorney – Richmond (SIDA)">District Attorney – Richmond (SIDA)</option>
<option value="Economic Development Corporation (EDC)">Economic Development Corporation (EDC)</option>
<option value="Emergency Medical Services (EMS)">Emergency Medical Services (EMS)</option>
<option value="Financial Information Services Agency (FISA)">Financial Information Services Agency (FISA)</option>
<option value="Fire Department (FDNY)">Fire Department (FDNY)</option>
<option value="Health and Hospitals Corporation (HHC)">Health and Hospitals Corporation (HHC)</option>
<option value="Human Resources Administration (HRA)">Human Resources Administration (HRA)</option>
<option value="Human Rights Commission (HRC)">Human Rights Commission (HRC)</option>
<option value="Independent Budget Office (IBO)">Independent Budget Office (IBO)</option>
<option value="Landmarks Preservation Commission (LPC) ">Landmarks Preservation Commission (LPC) </option>
<option value="Law Department (LAW)">Law Department (LAW)</option>
<option value="Mayor's Office">Mayor's Office </option>
<option value="New York City Comptroller's Office">New York City Comptroller's Office</option>
<option value="New York City Housing Authority (NYCHA)">New York City Housing Authority (NYCHA)</option>
<option value="New York City Employees Retirement System (NYCERS)">New York City Employees Retirement System (NYCERS)</option>
<option value="New York City School Construction Authority (SCA)">New York City School Construction Authority (SCA)</option>
<option value="Office of the Actuary (NYCOA)">Office of the Actuary (NYCOA)</option>
<option value="Office of Administrative Trials and Hearings (OATH)">Office of Administrative Trials and Hearings (OATH)</option>
<option value="Office of Chief Medical Examiner (OCME)">Office of Chief Medical Examiner (OCME)</option>
<option value="Office of Collective Bargaining (OCB)">Office of Collective Bargaining (OCB)</option>
<option value="Office of Management & Budget (OMB)">Office of Management & Budget (OMB)</option>
<option value="Office of the Mayor (MAYOR)">Office of the Mayor (MAYOR)</option>
<option value="Office of Payroll Management (OPA)">Office of Payroll Management (OPA)</option>
<option value="Police Department (NYPD)">Police Department (NYPD)</option>
<option value="Procurement Policy Board (PPB)">Procurement Policy Board (PPB)</option>
<option value="Public Administrator – New York (PANY)">Public Administrator – New York (PANY)</option>
<option value="Public Administrator – Bronx (PABX)">Public Administrator – Bronx (PABX)</option>
<option value="Public Administrator – Brooklyn (PABK)">Public Administrator – Brooklyn (PABK)</option>
<option value="Public Administrator – Queens (PAQN)">Public Administrator – Queens (PAQN)</option>
<option value="Public Administrator – Richmond (PASI)">Public Administrator – Richmond (PASI)</option>
<option value="Public Advocate – (PUBADV)">Public Advocate – (PUBADV)</option>
<option value="Rent Guidelines Board (RGB)">Rent Guidelines Board (RGB)</option>
<option value="Tax Appeals Tribunal">Tax Appeals Tribunal</option>
<option value="Tax Commission (TC)">Tax Commission (TC)</option>
<option value="Taxi & Limousine Commission (TLC)">Taxi & Limousine Commission (TLC)</option>
</select>
</div>
</div>
<div class="form-group">
<label for="subject2_title">Title (Include Rank and Shield Number if Applicable)</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-question-sign"></i></span>
<input type="text" class="form-control" id="subject2_title" name="subject2_title" placeholder="Enter subject title" maxlength="75">
</div>
</div>
</div> <!-- wells -->
</div> <!-- end of subject2_city_agency_show_hide -->
<div class="form-group has-feedback">
<label><span class="fieldRequired" id="subject2_company_name_required_label">*</span>Company Name</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-tower"></i></span>
<input type="text" class="form-control" id="subject2_company_name" name="subject2_company_name" placeholder="Enter Company Name" maxlength="75"
data-bv-field="subject2_company_name"><i class="form-control-feedback" data-bv-icon-for="subject2_company_name" style="display: none;"></i>
</div>
<small data-bv-validator="notEmpty" data-bv-validator-for="subject2_company_name" class="help-block" style="display: none;">Please enter company name</small>
</div>
<div class="form-group">
<label>EIN</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-tower"></i></span>
<input type="text" class="form-control" id="subject2_ein" name="subject2_ein" placeholder="Enter EIN(number only)" maxlength="15">
</div>
</div>
<div class="form-group has-feedback">
<label><span class="fieldRequired">*</span>Subject Address:</label>
<div class="radio"><label><input type="radio" name="subject2_address_type" value="Home" data-bv-field="subject2_address_type"> Home</label></div>
<div class="radio"><label><input type="radio" name="subject2_address_type" value="Business" data-bv-field="subject2_address_type"> Business</label></div>
<div class="radio"><label><input type="radio" name="subject2_address_type" value="Unknown" data-bv-field="subject2_address_type"><i class="form-control-feedback" data-bv-icon-for="subject2_address_type" style="display: none;"></i>
Unknown</label></div>
<small data-bv-validator="notEmpty" data-bv-validator-for="subject2_address_type" class="help-block" style="display: none;">Please select an option</small>
</div>
<div class="form-group">
<label for="subject2_street_address">Street Address</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-home"></i></span>
<input type="text" class="form-control" id="subject2_street_address" name="subject2_street_address" placeholder="Enter subject street address" maxlength="50">
</div>
</div>
<div class="form-group">
<label for="subject2_apt_number">Apt#/Room/Floor/Suite </label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-home"></i></span>
<input type="text" class="form-control" id="subject2_apt_number" name="subject2_apt_number" placeholder="Enter subject Apt#/Room/Floor/Suite" maxlength="75">
</div>
</div>
<div class="form-group">
<label for="subject2_city_town">City</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-home"></i></span>
<input type="text" class="form-control" id="subject2_city_town" name="subject2_city_town" placeholder="Enter subject City" maxlength="50">
</div>
</div>
<div class="form-group">
<label for="subject2_state">State</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-list"></i></span>
<select class="form-control" id="subject2_state" name="subject2_state">
<option value="" selected="" disabled="">Choose a State </option>
<option value="Alabama">Alabama</option>
<option value="Alaska">Alaska</option>
<option value="Arizona">Arizona</option>
<option value="Arkansas">Arkansas</option>
<option value="California">California</option>
<option value="Colorado">Colorado</option>
<option value="Connecticut">Connecticut</option>
<option value="Delaware">Delaware</option>
<option value="District of Columbia">District of Columbia</option>
<option value="Florida">Florida</option>
<option value="Georgia">Georgia</option>
<option value="Hawaii">Hawaii</option>
<option value="Idaho">Idaho</option>
<option value="Illinois">Illinois</option>
<option value="Indiana">Indiana</option>
<option value="Iowa">Iowa</option>
<option value="Kansas">Kansas</option>
<option value="Kentucky">Kentucky</option>
<option value="Louisiana">Louisiana</option>
<option value="Maine">Maine</option>
<option value="Maryland">Maryland</option>
<option value="Massachusetts">Massachusetts</option>
<option value="Michigan">Michigan</option>
<option value="Minnesota">Minnesota</option>
<option value="Mississippi">Mississippi</option>
<option value="Missouri">Missouri</option>
<option value="Montana">Montana</option>
<option value="Nebraska">Nebraska</option>
<option value="Nevada">Nevada</option>
<option value="New Hampshire">New Hampshire</option>
<option value="New Jersey">New Jersey</option>
<option value="New Mexico">New Mexico</option>
<option value="New York">New York</option>
<option value="North Carolina">North Carolina</option>
<option value="North Dakota">North Dakota</option>
<option value="Ohio">Ohio</option>
<option value="Oklahoma">Oklahoma</option>
<option value="Oregon">Oregon</option>
<option value="Pennsylvania">Pennsylvania</option>
<option value="Rhode Island">Rhode Island</option>
<option value="South Carolina">South Carolina</option>
<option value="South Dakota">South Dakota</option>
<option value="Tennessee">Tennessee</option>
<option value="Texas">Texas</option>
<option value="Utah">Utah</option>
<option value="Vermont">Vermont</option>
<option value="Virginia">Virginia</option>
<option value="Washington">Washington</option>
<option value="West Virginia">West Virginia</option>
<option value="Wisconsin">Wisconsin</option>
<option value="Wyoming">Wyoming</option>
</select>
</div>
</div>
<div class="form-group has-feedback">
<label for="subject2_zip_code">Zip Code</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-home"></i></span>
<input type="text" class="form-control" id="subject2_zip_code" name="subject2_zip_code" placeholder="Enter subject zip code" maxlength="5"
data-bv-field="subject2_zip_code"><i class="form-control-feedback" data-bv-icon-for="subject2_zip_code" style="display: none;"></i>
</div>
<small data-bv-validator="zipCode" data-bv-validator-for="subject2_zip_code" class="help-block" style="display: none;">Please enter a valid zip code or leave it blank</small>
</div>
<div class="form-group">
<label>Primary Phone</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-phone"></i></span>
<input type="text" class="form-control input-medium bfh-phone" data-format=" (ddd) ddd-dddd" id="subject2_primary_phone" name="subject2_primary_phone" maxlength="15">
</div>
</div>
<div class="form-group">
<label>Secondary Phone</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-phone"></i></span>
<input type="text" class="form-control input-medium bfh-phone" data-format=" (ddd) ddd-dddd" id="subject2_secondary_phone" name="subject2_secondary_phone" maxlength="15">
</div>
</div>
<div class="form-group has-feedback">
<label for="subject2_website">Website</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-globe"></i></span>
<input type="text" class="form-control" id="subject2_website" name="subject2_website" placeholder="Enter subject website" maxlength="300"
data-bv-field="subject2_website"><i class="form-control-feedback" data-bv-icon-for="subject2_website" style="display: none;"></i>
</div>
<small data-bv-validator="uri" data-bv-validator-for="subject2_website" class="help-block" style="display: none;">The website address is not valid</small>
</div>
<div class="form-group has-feedback">
<label for="subject2_email">Email Address</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-envelope"></i></span>
<input type="text" class="form-control" id="subject2_email" name="subject2_email" placeholder="Enter subject email address" maxlength="75"
data-bv-field="subject2_email"><i class="form-control-feedback" data-bv-icon-for="subject2_email" style="display: none;"></i>
</div>
<small data-bv-validator="emailAddress" data-bv-validator-for="subject2_email" class="help-block" style="display: none;">Please enter a valid email address or leave it blank</small>
</div>
<div class="well well_rb">
<div class="form-group">
<label>Are there any additional addresses involved in this complaint?</label>
<div class="radio"><label><input type="radio" id="subject2_address2_involved" name="subject2_address2_involved" value="Yes">Yes</label></div>
<div class="radio"><label><input type="radio" id="subject2_address2_involved" name="subject2_address2_involved" value="No">No</label></div>
</div>
<!-- additional address start -->
<div id="subject2_address2_show_hide" style="display:none;">
<div class="form-group has-feedback">
<label><span class="fieldRequired">*</span>Subject Address:</label>
<div class="radio"><label><input type="radio" name="subject2_address2_type" value="Home" data-bv-field="subject2_address2_type"> Home</label></div>
<div class="radio"><label><input type="radio" name="subject2_address2_type" value="Business" data-bv-field="subject2_address2_type"> Business</label></div>
<div class="radio"><label><input type="radio" name="subject2_address2_type" value="Unknown" data-bv-field="subject2_address2_type"><i class="form-control-feedback" data-bv-icon-for="subject2_address2_type" style="display: none;"></i>
Unknown</label></div>
<small data-bv-validator="notEmpty" data-bv-validator-for="subject2_address2_type" class="help-block" style="display: none;">Please select an option</small>
</div>
<div class="form-group">
<label for="subject2_street_address2">Street Address</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-home"></i></span>
<input type="text" class="form-control" id="subject2_street_address2" name="subject2_street_address2" placeholder="Enter subject street address" maxlength="50">
</div>
</div>
<div class="form-group">
<label for="subject2_apt_number2">Apt#/Room/Floor/Suite</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-home"></i></span>
<input type="text" class="form-control" id="subject2_apt_number2" name="subject2_apt_number2" placeholder="Enter subject Apt#/Room/Floor/Suite" maxlength="75">
</div>
</div>
<div class="form-group">
<label for="subject2_city_town2">City</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-home"></i></span>
<input type="text" class="form-control" id="subject2_city_town2" name="subject2_city_town2" placeholder="Enter subject City" maxlength="50">
</div>
</div>
<div class="form-group">
<label for="subject2_state2">State</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-list"></i></span>
<select class="form-control" id="subject2_state2" name="subject2_state2">
<option value="" selected="" disabled="">Choose a State </option>
<option value="Alabama">Alabama</option>
<option value="Alaska">Alaska</option>
<option value="Arizona">Arizona</option>
<option value="Arkansas">Arkansas</option>
<option value="California">California</option>
<option value="Colorado">Colorado</option>
<option value="Connecticut">Connecticut</option>
<option value="Delaware">Delaware</option>
<option value="District of Columbia">District of Columbia</option>
<option value="Florida">Florida</option>
<option value="Georgia">Georgia</option>
<option value="Hawaii">Hawaii</option>
<option value="Idaho">Idaho</option>
<option value="Illinois">Illinois</option>
<option value="Indiana">Indiana</option>
<option value="Iowa">Iowa</option>
<option value="Kansas">Kansas</option>
<option value="Kentucky">Kentucky</option>
<option value="Louisiana">Louisiana</option>
<option value="Maine">Maine</option>
<option value="Maryland">Maryland</option>
<option value="Massachusetts">Massachusetts</option>
<option value="Michigan">Michigan</option>
<option value="Minnesota">Minnesota</option>
<option value="Mississippi">Mississippi</option>
<option value="Missouri">Missouri</option>
<option value="Montana">Montana</option>
<option value="Nebraska">Nebraska</option>
<option value="Nevada">Nevada</option>
<option value="New Hampshire">New Hampshire</option>
<option value="New Jersey">New Jersey</option>
<option value="New Mexico">New Mexico</option>
<option value="New York">New York</option>
<option value="North Carolina">North Carolina</option>
<option value="North Dakota">North Dakota</option>
<option value="Ohio">Ohio</option>
<option value="Oklahoma">Oklahoma</option>
<option value="Oregon">Oregon</option>
<option value="Pennsylvania">Pennsylvania</option>
<option value="Rhode Island">Rhode Island</option>
<option value="South Carolina">South Carolina</option>
<option value="South Dakota">South Dakota</option>
<option value="Tennessee">Tennessee</option>
<option value="Texas">Texas</option>
<option value="Utah">Utah</option>
<option value="Vermont">Vermont</option>
<option value="Virginia">Virginia</option>
<option value="Washington">Washington</option>
<option value="West Virginia">West Virginia</option>
<option value="Wisconsin">Wisconsin</option>
<option value="Wyoming">Wyoming</option>
</select>
</div>
</div>
<div class="form-group has-feedback">
<label for="subject2_zip_code2">Zip Code</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-home"></i></span>
<input type="text" class="form-control" id="subject2_zip_code2" name="subject2_zip_code2" placeholder="Enter subject zip code" maxlength="5"
data-bv-field="subject2_zip_code2"><i class="form-control-feedback" data-bv-icon-for="subject2_zip_code2" style="display: none;"></i>
</div>
<small data-bv-validator="zipCode" data-bv-validator-for="subject2_zip_code2" class="help-block" style="display: none;">Please enter a valid zip code or leave it blank</small>
</div>
<div class="form-group">
<label>Primary Phone</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-phone"></i></span>
<input type="text" class="form-control input-medium bfh-phone" data-format=" (ddd) ddd-dddd" id="subject2_primary_phone2" name="subject2_primary_phone2" maxlength="15">
</div>
</div>
<div class="form-group">
<label>Secondary Phone</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-phone"></i></span>
<input type="text" class="form-control input-medium bfh-phone" data-format=" (ddd) ddd-dddd" id="subject2_secondary_phone2" name="subject2_secondary_phone2" maxlength="15">
</div>
</div>
<div class="form-group has-feedback">
<label for="subject2_website2">Website</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-globe"></i></span>
<input type="text" class="form-control" id="subject2_website2" name="subject2_website2" placeholder="Enter subject website" maxlength="300"
data-bv-field="subject2_website2"><i class="form-control-feedback" data-bv-icon-for="subject2_website2" style="display: none;"></i>
</div>
<small data-bv-validator="uri" data-bv-validator-for="subject2_website2" class="help-block" style="display: none;">The website address is not valid</small>
</div>
<div class="form-group has-feedback">
<label for="subject2_email2">Email Address</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-envelope"></i></span>
<input type="text" class="form-control" id="subject2_email2" name="subject2_email2" placeholder="Enter subject email address" maxlength="75"
data-bv-field="subject2_email2"><i class="form-control-feedback" data-bv-icon-for="subject2_email2" style="display: none;"></i>
</div>
<small data-bv-validator="emailAddress" data-bv-validator-for="subject2_email2" class="help-block" style="display: none;">Please enter a valid email address or leave it blank</small>
</div>
</div> <!-- end of 'well well_rb' -->
</div> <!-- end of 'subject2_address2_show_hide' -->
</div> <!-- end of subject2_show_hide div -->
</div> <!-- end of well div -->
<!-- END of additional subject information ---------------------------------------------------------------------------------------------->
<!-- END of additional subject information ---------------------------------------------------------------------------------------------->
</div> <!-- end of panel body -->
</div> <!-- end of panel -->
<!-- END of subject information --------------------------------------------------------------------------------------------------------->
<!-- END of subject information --------------------------------------------------------------------------------------------------------->
<!-- START of participant information -------------------------------------------------------------------------------------------------->
<!-- START of participant information -------------------------------------------------------------------------------------------------->
<div class="panel panel-default">
<div class="panel-heading">WITNESS / VICTIM / OTHER COMPANY INFORMATION</div>
<div class="panel-body">
<div class="form-group has-feedback">
<label><span class="fieldRequired">*</span>Are there any witnesses, victims, and/or other companies involved in this complaint?</label>
<div class="radio"><label><input type="radio" id="participant_involved" name="participant_involved" value="Yes" data-bv-field="participant_involved"> Yes</label></div>
<div class="radio"><label><input type="radio" id="participant_involved" name="participant_involved" value="No"
data-bv-field="participant_involved"><i class="form-control-feedback" data-bv-icon-for="participant_involved" style="display: none;"></i> No</label></div>
<small data-bv-validator="notEmpty" data-bv-validator-for="participant_involved" class="help-block" style="display: none;">Please select an option</small>
</div>
<div id="participant_show_hide" style="display:none;">
<div class="form-group has-feedback">
<label><span class="fieldRequired">*</span>The other party involved is a:</label>
<div class="radio"><label><input type="radio" id="participant_type" name="participant_type" value="Witness" data-bv-field="participant_type"> Witness</label></div>
<div class="radio"><label><input type="radio" id="participant_type" name="participant_type" value="Victim" data-bv-field="participant_type"> Victim</label></div>
<div class="radio"><label><input type="radio" id="participant_type" name="participant_type" value="Other Company"
data-bv-field="participant_type"><i class="form-control-feedback" data-bv-icon-for="participant_type" style="display: none;"></i> Other Company</label></div>
<small data-bv-validator="notEmpty" data-bv-validator-for="participant_type" class="help-block" style="display: none;">Please select an option</small>
</div>
<div class="form-group">
<label for="participant_first_name">First Name</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-user"></i></span>
<input type="text" class="form-control" id="participant_first_name" name="participant_first_name" placeholder="Enter first name" maxlength="50">
</div>
</div>
<div class="form-group">
<label for="participant_last_name">Last Name</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-user"></i></span>
<input type="text" class="form-control" id="participant_last_name" name="participant_last_name" placeholder="Enter last name" maxlength="50">
</div>
</div>
<div class="form-group">
<label for="participant_nickname">Nickname</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-user"></i></span>
<input type="text" class="form-control" id="participant_nickname" name="participant_nickname" placeholder="Enter nickname" maxlength="50">
</div>
</div>
<!--
<div class = "form-group">
<label >Date of Birth(mm/dd/yyyy)</label>
<div class='input-group date' id="participant_dob" >
<input type='text' class="form-control" name="participant_dob" id="participant_dob_focus" />
<span class="input-group-addon"><span class="glyphicon glyphicon-calendar"></span></span>
</div>
</div>
-->
<div class="form-group">
<label>Date of Birth</label><br>
<input type="text" id="participant_dob_combo" data-format="MM/DD/YYYY" data-template="MM DD YYYY" name="participant_dob_combo" style="display: none;"><span class="combodate"><select class="month " style="width: auto;">
<option value=""></option>
<option value="0">01</option>
<option value="1">02</option>
<option value="2">03</option>
<option value="3">04</option>
<option value="4">05</option>
<option value="5">06</option>
<option value="6">07</option>
<option value="7">08</option>
<option value="8">09</option>
<option value="9">10</option>
<option value="10">11</option>
<option value="11">12</option>
</select> <select class="day " style="width: auto;">
<option value=""></option>
<option value="1">01</option>
<option value="2">02</option>
<option value="3">03</option>
<option value="4">04</option>
<option value="5">05</option>
<option value="6">06</option>
<option value="7">07</option>
<option value="8">08</option>
<option value="9">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
</select> <select class="year " style="width: auto;">
<option value=""></option>
<option value="2024">2024</option>
<option value="2023">2023</option>
<option value="2022">2022</option>
<option value="2021">2021</option>
<option value="2020">2020</option>
<option value="2019">2019</option>
<option value="2018">2018</option>
<option value="2017">2017</option>
<option value="2016">2016</option>
<option value="2015">2015</option>
<option value="2014">2014</option>
<option value="2013">2013</option>
<option value="2012">2012</option>
<option value="2011">2011</option>
<option value="2010">2010</option>
<option value="2009">2009</option>
<option value="2008">2008</option>
<option value="2007">2007</option>
<option value="2006">2006</option>
<option value="2005">2005</option>
<option value="2004">2004</option>
<option value="2003">2003</option>
<option value="2002">2002</option>
<option value="2001">2001</option>
<option value="2000">2000</option>
<option value="1999">1999</option>
<option value="1998">1998</option>
<option value="1997">1997</option>
<option value="1996">1996</option>
<option value="1995">1995</option>
<option value="1994">1994</option>
<option value="1993">1993</option>
<option value="1992">1992</option>
<option value="1991">1991</option>
<option value="1990">1990</option>
<option value="1989">1989</option>
<option value="1988">1988</option>
<option value="1987">1987</option>
<option value="1986">1986</option>
<option value="1985">1985</option>
<option value="1984">1984</option>
<option value="1983">1983</option>
<option value="1982">1982</option>
<option value="1981">1981</option>
<option value="1980">1980</option>
<option value="1979">1979</option>
<option value="1978">1978</option>
<option value="1977">1977</option>
<option value="1976">1976</option>
<option value="1975">1975</option>
<option value="1974">1974</option>
<option value="1973">1973</option>
<option value="1972">1972</option>
<option value="1971">1971</option>
<option value="1970">1970</option>
<option value="1969">1969</option>
<option value="1968">1968</option>
<option value="1967">1967</option>
<option value="1966">1966</option>
<option value="1965">1965</option>
<option value="1964">1964</option>
<option value="1963">1963</option>
<option value="1962">1962</option>
<option value="1961">1961</option>
<option value="1960">1960</option>
<option value="1959">1959</option>
<option value="1958">1958</option>
<option value="1957">1957</option>
<option value="1956">1956</option>
<option value="1955">1955</option>
<option value="1954">1954</option>
<option value="1953">1953</option>
<option value="1952">1952</option>
<option value="1951">1951</option>
<option value="1950">1950</option>
<option value="1949">1949</option>
<option value="1948">1948</option>
<option value="1947">1947</option>
<option value="1946">1946</option>
<option value="1945">1945</option>
<option value="1944">1944</option>
<option value="1943">1943</option>
<option value="1942">1942</option>
<option value="1941">1941</option>
<option value="1940">1940</option>
<option value="1939">1939</option>
<option value="1938">1938</option>
<option value="1937">1937</option>
<option value="1936">1936</option>
<option value="1935">1935</option>
<option value="1934">1934</option>
<option value="1933">1933</option>
<option value="1932">1932</option>
<option value="1931">1931</option>
<option value="1930">1930</option>
<option value="1929">1929</option>
<option value="1928">1928</option>
<option value="1927">1927</option>
<option value="1926">1926</option>
<option value="1925">1925</option>
<option value="1924">1924</option>
<option value="1923">1923</option>
<option value="1922">1922</option>
<option value="1921">1921</option>
<option value="1920">1920</option>
<option value="1919">1919</option>
<option value="1918">1918</option>
<option value="1917">1917</option>
<option value="1916">1916</option>
<option value="1915">1915</option>
<option value="1914">1914</option>
<option value="1913">1913</option>
<option value="1912">1912</option>
<option value="1911">1911</option>
<option value="1910">1910</option>
<option value="1909">1909</option>
<option value="1908">1908</option>
<option value="1907">1907</option>
<option value="1906">1906</option>
<option value="1905">1905</option>
<option value="1904">1904</option>
<option value="1903">1903</option>
<option value="1902">1902</option>
<option value="1901">1901</option>
<option value="1900">1900</option>
</select></span>
</div>
<div class="form-group">
<label>Is the other party involved a City Employee?</label>
<div class="form-group">
<label class="radio-inline"><input type="radio" name="participant_is_city_employee" value="Yes">Yes</label>
<label class="radio-inline"><input type="radio" name="participant_is_city_employee" value="No">No</label>
<label class="radio-inline"><input type="radio" name="participant_is_city_employee" value="Unknown">Unknown</label>
</div>
</div>
<div id="participant_city_agency_show_hide" style="display:none;">
<div class="well well_rb">
<div class="form-group">
<label for="participant_city_agency">Select City Agency:</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-list"></i></span>
<select class="form-control" id="participant_city_agency" name="participant_city_agency">
<option value="" selected="" disabled="">Choose a City Agency </option>
<option value="Administration for Children Services (ACS)">Administration for Children Services (ACS)</option>
<option value="Board of Election (BOE)">Board of Election (BOE)</option>
<option value="Board of Estimate (BDEST)">Board of Estimate (BDEST)</option>
<option value="Board of Standards and Appeals (BSA)">Board of Standards and Appeals (BSA)</option>
<option value="Borough President – Bronx">Borough President – Bronx</option>
<option value="Borough President – Brooklyn">Borough President – Brooklyn</option>
<option value="Borough President – Manhattan">Borough President – Manhattan</option>
<option value="Borough President – Queens">Borough President – Queens</option>
<option value="Borough President – Staten Island">Borough President – Staten Island</option>
<option value="Business Integrity Commission (BIC)">Business Integrity Commission (BIC)</option>
<option value="Campaign Finance Board (CFB)">Campaign Finance Board (CFB)</option>
<option value="City Clerk's Office">City Clerk's Office</option>
<option value="City Council">City Council</option>
<option value="City Marshal">City Marshal</option>
<option value="City Sheriff (Sheriff)">City Sheriff (Sheriff) </option>
<option value="City University of New York (CUNY)">City University of New York (CUNY)</option>
<option value="Civil Service Commission (CSC)">Civil Service Commission (CSC)</option>
<option value="Civilian Complaint Review Board (CCRB)">Civilian Complaint Review Board (CCRB)</option>
<option value="Commission on Human Rights (CCHR)">Commission on Human Rights (CCHR)</option>
<option value="Community Board – Manhattan">Community Board – Manhattan</option>
<option value="Community Board – Brooklyn">Community Board – Brooklyn</option>
<option value="Community Board – Bronx">Community Board – Bronx</option>
<option value="Community Board – Queens">Community Board – Queens</option>
<option value="Community Board – Staten Island">Community Board – Staten Island</option>
<option value="Conflicts of Interest Board (COIB)">Conflicts of Interest Board (COIB)</option>
<option value="Department for the Aging (DFTA)">Department for the Aging (DFTA)</option>
<option value="Department of Buildings (DOB)">Department of Buildings (DOB)</option>
<option value="Department of City Planning (DCP)">Department of City Planning (DCP)</option>
<option value="Department of Citywide Administrative Services (DCAS)">Department of Citywide Administrative Services (DCAS)</option>
<option value="Department of Consumer Affairs (DCA)">Department of Consumer Affairs (DCA)</option>
<option value="Department of Correction (DOC)">Department of Correction (DOC)</option>
<option value="Department of Cultural Affairs (DCLA)">Department of Cultural Affairs (DCLA)</option>
<option value="Department of Design & Construction (DDC)">Department of Design & Construction (DDC)</option>
<option value="Department of Education (DOE)">Department of Education (DOE)</option>
<option value="Department of Environmental Protection (DEP)">Department of Environmental Protection (DEP)</option>
<option value="Department of Finance (DOF)">Department of Finance (DOF)</option>
<option value="Department of Health & Mental Hygiene (DOHMH)">Department of Health & Mental Hygiene (DOHMH)</option>
<option value="Department of Homeless Services (DHS)">Department of Homeless Services (DHS)</option>
<option value="Department of Housing Preservation & Development (HPD)">Department of Housing Preservation & Development (HPD)</option>
<option value="Department of Information Technology & Telecommunications (DoITT)">Department of Information Technology & Telecommunications (DoITT)</option>
<option value="Department of Investigation (DOI)">Department of Investigation (DOI)</option>
<option value="Department of Parks & Recreation (Parks)">Department of Parks & Recreation (Parks)</option>
<option value="Department of Probation (DOP)">Department of Probation (DOP)</option>
<option value="Department of Records & Information Services (DORIS)">Department of Records & Information Services (DORIS)</option>
<option value="Department of Sanitation (DSNY)">Department of Sanitation (DSNY)</option>
<option value="Department of Small Business Services (SBS)">Department of Small Business Services (SBS)</option>
<option value="Department of Transportation (DOT)">Department of Transportation (DOT)</option>
<option value="Department of Youth & Community Development (DYCD)">Department of Youth & Community Development (DYCD)</option>
<option value="Department of Youth & Family Justice (DYFJ)">Department of Youth & Family Justice (DYFJ)</option>
<option value="District Attorney – Manhattan (NYDA)">District Attorney – Manhattan (NYDA)</option>
<option value="District Attorney – Brooklyn (BKDA)">District Attorney – Brooklyn (BKDA)</option>
<option value="District Attorney – Queens (QNDA)">District Attorney – Queens (QNDA)</option>
<option value="District Attorney – Bronx (BXDA)">District Attorney – Bronx (BXDA)</option>
<option value="District Attorney – Richmond (SIDA)">District Attorney – Richmond (SIDA)</option>
<option value="Economic Development Corporation (EDC)">Economic Development Corporation (EDC)</option>
<option value="Emergency Medical Services (EMS)">Emergency Medical Services (EMS)</option>
<option value="Financial Information Services Agency (FISA)">Financial Information Services Agency (FISA)</option>
<option value="Fire Department (FDNY)">Fire Department (FDNY)</option>
<option value="Health and Hospitals Corporation (HHC)">Health and Hospitals Corporation (HHC)</option>
<option value="Human Resources Administration (HRA)">Human Resources Administration (HRA)</option>
<option value="Human Rights Commission (HRC)">Human Rights Commission (HRC)</option>
<option value="Independent Budget Office (IBO)">Independent Budget Office (IBO)</option>
<option value="Landmarks Preservation Commission (LPC) ">Landmarks Preservation Commission (LPC) </option>
<option value="Law Department (LAW)">Law Department (LAW)</option>
<option value="Mayor's Office">Mayor's Office </option>
<option value="New York City Comptroller's Office">New York City Comptroller's Office</option>
<option value="New York City Housing Authority (NYCHA)">New York City Housing Authority (NYCHA)</option>
<option value="New York City Employees Retirement System (NYCERS)">New York City Employees Retirement System (NYCERS)</option>
<option value="New York City School Construction Authority (SCA)">New York City School Construction Authority (SCA)</option>
<option value="Office of the Actuary (NYCOA)">Office of the Actuary (NYCOA)</option>
<option value="Office of Administrative Trials and Hearings (OATH)">Office of Administrative Trials and Hearings (OATH)</option>
<option value="Office of Chief Medical Examiner (OCME)">Office of Chief Medical Examiner (OCME)</option>
<option value="Office of Collective Bargaining (OCB)">Office of Collective Bargaining (OCB)</option>
<option value="Office of Management & Budget (OMB)">Office of Management & Budget (OMB)</option>
<option value="Office of the Mayor (MAYOR)">Office of the Mayor (MAYOR)</option>
<option value="Office of Payroll Management (OPA)">Office of Payroll Management (OPA)</option>
<option value="Police Department (NYPD)">Police Department (NYPD)</option>
<option value="Procurement Policy Board (PPB)">Procurement Policy Board (PPB)</option>
<option value="Public Administrator – New York (PANY)">Public Administrator – New York (PANY)</option>
<option value="Public Administrator – Bronx (PABX)">Public Administrator – Bronx (PABX)</option>
<option value="Public Administrator – Brooklyn (PABK)">Public Administrator – Brooklyn (PABK)</option>
<option value="Public Administrator – Queens (PAQN)">Public Administrator – Queens (PAQN)</option>
<option value="Public Administrator – Richmond (PASI)">Public Administrator – Richmond (PASI)</option>
<option value="Public Advocate – (PUBADV)">Public Advocate – (PUBADV)</option>
<option value="Rent Guidelines Board (RGB)">Rent Guidelines Board (RGB)</option>
<option value="Tax Appeals Tribunal">Tax Appeals Tribunal</option>
<option value="Tax Commission (TC)">Tax Commission (TC)</option>
<option value="Taxi & Limousine Commission (TLC)">Taxi & Limousine Commission (TLC)</option>
</select>
</div>
</div>
<div class="form-group">
<label for="participant_title">Title (Include Rank and Shield Number if Applicable)</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-question-sign"></i></span>
<input type="text" class="form-control" id="participant_title" name="participant_title" placeholder="Enter title" maxlength="75">
</div>
</div>
</div> <!-- wells -->
</div> <!-- participant_city_agency_show_hide-->
<div class="form-group">
<label for="participant_company_name">Company Name</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-tower"></i></span>
<input type="text" class="form-control" id="participant_company_name" name="participant_company_name" placeholder="Enter company name" maxlength="75">
</div>
</div>
<div class="form-group">
<label for="participant_ein">EIN</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-tower"></i></span>
<input type="text" class="form-control" id="participant_ein" name="participant_ein" placeholder="Enter EIN(number only)" maxlength="15">
</div>
</div>
<div class="form-group">
<label>Other Party Involved Address:</label>
<div class="form-group">
<label class="radio-inline"><input type="radio" name="participant_address_type" value="Home">Home</label>
<label class="radio-inline"><input type="radio" name="participant_address_type" value="Business">Business</label>
<label class="radio-inline"><input type="radio" name="participant_address_type" value="Unknown">Unknown</label>
</div>
</div>
<div class="form-group">
<label for="participant_street_address">Street Address</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-home"></i></span>
<input type="text" class="form-control" id="participant_street_address" name="participant_street_address" placeholder="Enter street address" maxlength="50">
</div>
</div>
<div class="form-group">
<label for="participant_apt_number">Apt#/Room/Floor/Suite</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-home"></i></span>
<input type="text" class="form-control" id="participant_apt_number" name="participant_apt_number" placeholder="Enter Apt#/Room/Floor/Suite" maxlength="75">
</div>
</div>
<div class="form-group">
<label for="participant_city_town">City</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-home"></i></span>
<input type="text" class="form-control" id="participant_city_town" name="participant_city_town" placeholder="Enter City" maxlength="50">
</div>
</div>
<div class="form-group">
<label for="participant_state">State</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-list"></i></span>
<select class="form-control" id="participant_state" name="participant_state">
<option value="" selected="" disabled="">Choose a State </option>
<option value="Alabama">Alabama</option>
<option value="Alaska">Alaska</option>
<option value="Arizona">Arizona</option>
<option value="Arkansas">Arkansas</option>
<option value="California">California</option>
<option value="Colorado">Colorado</option>
<option value="Connecticut">Connecticut</option>
<option value="Delaware">Delaware</option>
<option value="District of Columbia">District of Columbia</option>
<option value="Florida">Florida</option>
<option value="Georgia">Georgia</option>
<option value="Hawaii">Hawaii</option>
<option value="Idaho">Idaho</option>
<option value="Illinois">Illinois</option>
<option value="Indiana">Indiana</option>
<option value="Iowa">Iowa</option>
<option value="Kansas">Kansas</option>
<option value="Kentucky">Kentucky</option>
<option value="Louisiana">Louisiana</option>
<option value="Maine">Maine</option>
<option value="Maryland">Maryland</option>
<option value="Massachusetts">Massachusetts</option>
<option value="Michigan">Michigan</option>
<option value="Minnesota">Minnesota</option>
<option value="Mississippi">Mississippi</option>
<option value="Missouri">Missouri</option>
<option value="Montana">Montana</option>
<option value="Nebraska">Nebraska</option>
<option value="Nevada">Nevada</option>
<option value="New Hampshire">New Hampshire</option>
<option value="New Jersey">New Jersey</option>
<option value="New Mexico">New Mexico</option>
<option value="New York">New York</option>
<option value="North Carolina">North Carolina</option>
<option value="North Dakota">North Dakota</option>
<option value="Ohio">Ohio</option>
<option value="Oklahoma">Oklahoma</option>
<option value="Oregon">Oregon</option>
<option value="Pennsylvania">Pennsylvania</option>
<option value="Rhode Island">Rhode Island</option>
<option value="South Carolina">South Carolina</option>
<option value="South Dakota">South Dakota</option>
<option value="Tennessee">Tennessee</option>
<option value="Texas">Texas</option>
<option value="Utah">Utah</option>
<option value="Vermont">Vermont</option>
<option value="Virginia">Virginia</option>
<option value="Washington">Washington</option>
<option value="West Virginia">West Virginia</option>
<option value="Wisconsin">Wisconsin</option>
<option value="Wyoming">Wyoming</option>
</select>
</div>
</div>
<div class="form-group has-feedback">
<label for="participant_zip_code">Zip Code</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-home"></i></span>
<input type="text" class="form-control" id="participant_zip_code" name="participant_zip_code" placeholder="Enter zip code" maxlength="5"
data-bv-field="participant_zip_code"><i class="form-control-feedback" data-bv-icon-for="participant_zip_code" style="display: none;"></i>
</div>
<small data-bv-validator="zipCode" data-bv-validator-for="participant_zip_code" class="help-block" style="display: none;">Please enter a valid zip code or leave it blank</small>
</div>
<div class="form-group">
<label>Primary Phone</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-phone"></i></span>
<input type="text" class="form-control input-medium bfh-phone" data-format=" (ddd) ddd-dddd" id="participant_primary_phone" name="participant_primary_phone" maxlength="15">
</div>
</div>
<div class="form-group">
<label>Secondary Phone</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-phone"></i></span>
<input type="text" class="form-control input-medium bfh-phone" data-format=" (ddd) ddd-dddd" id="participant_secondary_phone" name="participant_secondary_phone" maxlength="15">
</div>
</div>
<div class="form-group has-feedback">
<label for="participant_website">Website</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-globe"></i></span>
<input type="text" class="form-control" id="participant_website" name="participant_website" placeholder="Enter website" maxlength="300"
data-bv-field="participant_website"><i class="form-control-feedback" data-bv-icon-for="participant_website" style="display: none;"></i>
</div>
<small data-bv-validator="uri" data-bv-validator-for="participant_website" class="help-block" style="display: none;">The website address is not valid</small>
</div>
<div class="form-group has-feedback">
<label for="participant_email">Email Address</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-envelope"></i></span>
<input type="text" class="form-control" id="participant_email" name="participant_email" placeholder="Enter email address" maxlength="75"
data-bv-field="participant_email"><i class="form-control-feedback" data-bv-icon-for="participant_email" style="display: none;"></i>
</div>
<small data-bv-validator="emailAddress" data-bv-validator-for="participant_email" class="help-block" style="display: none;">Please enter a valid email address or leave it blank</small>
</div>
<div class="well">
<label>Are there any additional witnesses, victims, and/or other companies involved in this complaint?</label>
<div class="form-group">
<label class="radio-inline"><input type="radio" name="participant_additional" value="Yes">Yes</label>
<label class="radio-inline"><input type="radio" name="participant_additional" value="No">No</label>
</div>
<!-- START of additional participant information ----------------------------------------------------------------------------------------------------------->
<div id="participant2_show_hide" style="display:none;">
<div class="form-group has-feedback">
<label><span class="fieldRequired">*</span>The other party involved is a:</label>
<div class="radio"><label><input type="radio" id="participant2_type" name="participant2_type" value="Witness" data-bv-field="participant2_type"> Witness</label></div>
<div class="radio"><label><input type="radio" id="participant2_type" name="participant2_type" value="Victim" data-bv-field="participant2_type"> Victim</label></div>
<div class="radio"><label><input type="radio" id="participant2_type" name="participant2_type" value="Other Company"
data-bv-field="participant2_type"><i class="form-control-feedback" data-bv-icon-for="participant2_type" style="display: none;"></i> Other Company</label></div>
<small data-bv-validator="notEmpty" data-bv-validator-for="participant2_type" class="help-block" style="display: none;">Please select an option</small>
</div>
<div class="form-group">
<label for="participant2_first_name">First Name</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-user"></i></span>
<input type="text" class="form-control" id="participant2_first_name" name="participant2_first_name" placeholder="Enter first name" maxlength="50">
</div>
</div>
<div class="form-group">
<label for="participant2_last_name">Last Name</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-user"></i></span>
<input type="text" class="form-control" id="participant2_last_name" name="participant2_last_name" placeholder="Enter last name" maxlength="50">
</div>
</div>
<!--
<div class = "form-group">
<label >Date of Birth(mm/dd/yyyy)</label>
<div class='input-group date' id="participant2_dob" >
<input type='text' class="form-control" name="participant2_dob" id="participant2_dob_focus" />
<span class="input-group-addon"><span class="glyphicon glyphicon-calendar"></span></span>
</div>
</div>
-->
<div class="form-group">
<label>Date of Birth</label><br>
<input type="text" id="participant2_dob_combo" data-format="MM/DD/YYYY" data-template="MM DD YYYY" name="participant2_dob_combo" style="display: none;"><span class="combodate"><select class="month " style="width: auto;">
<option value=""></option>
<option value="0">01</option>
<option value="1">02</option>
<option value="2">03</option>
<option value="3">04</option>
<option value="4">05</option>
<option value="5">06</option>
<option value="6">07</option>
<option value="7">08</option>
<option value="8">09</option>
<option value="9">10</option>
<option value="10">11</option>
<option value="11">12</option>
</select> <select class="day " style="width: auto;">
<option value=""></option>
<option value="1">01</option>
<option value="2">02</option>
<option value="3">03</option>
<option value="4">04</option>
<option value="5">05</option>
<option value="6">06</option>
<option value="7">07</option>
<option value="8">08</option>
<option value="9">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
</select> <select class="year " style="width: auto;">
<option value=""></option>
<option value="2024">2024</option>
<option value="2023">2023</option>
<option value="2022">2022</option>
<option value="2021">2021</option>
<option value="2020">2020</option>
<option value="2019">2019</option>
<option value="2018">2018</option>
<option value="2017">2017</option>
<option value="2016">2016</option>
<option value="2015">2015</option>
<option value="2014">2014</option>
<option value="2013">2013</option>
<option value="2012">2012</option>
<option value="2011">2011</option>
<option value="2010">2010</option>
<option value="2009">2009</option>
<option value="2008">2008</option>
<option value="2007">2007</option>
<option value="2006">2006</option>
<option value="2005">2005</option>
<option value="2004">2004</option>
<option value="2003">2003</option>
<option value="2002">2002</option>
<option value="2001">2001</option>
<option value="2000">2000</option>
<option value="1999">1999</option>
<option value="1998">1998</option>
<option value="1997">1997</option>
<option value="1996">1996</option>
<option value="1995">1995</option>
<option value="1994">1994</option>
<option value="1993">1993</option>
<option value="1992">1992</option>
<option value="1991">1991</option>
<option value="1990">1990</option>
<option value="1989">1989</option>
<option value="1988">1988</option>
<option value="1987">1987</option>
<option value="1986">1986</option>
<option value="1985">1985</option>
<option value="1984">1984</option>
<option value="1983">1983</option>
<option value="1982">1982</option>
<option value="1981">1981</option>
<option value="1980">1980</option>
<option value="1979">1979</option>
<option value="1978">1978</option>
<option value="1977">1977</option>
<option value="1976">1976</option>
<option value="1975">1975</option>
<option value="1974">1974</option>
<option value="1973">1973</option>
<option value="1972">1972</option>
<option value="1971">1971</option>
<option value="1970">1970</option>
<option value="1969">1969</option>
<option value="1968">1968</option>
<option value="1967">1967</option>
<option value="1966">1966</option>
<option value="1965">1965</option>
<option value="1964">1964</option>
<option value="1963">1963</option>
<option value="1962">1962</option>
<option value="1961">1961</option>
<option value="1960">1960</option>
<option value="1959">1959</option>
<option value="1958">1958</option>
<option value="1957">1957</option>
<option value="1956">1956</option>
<option value="1955">1955</option>
<option value="1954">1954</option>
<option value="1953">1953</option>
<option value="1952">1952</option>
<option value="1951">1951</option>
<option value="1950">1950</option>
<option value="1949">1949</option>
<option value="1948">1948</option>
<option value="1947">1947</option>
<option value="1946">1946</option>
<option value="1945">1945</option>
<option value="1944">1944</option>
<option value="1943">1943</option>
<option value="1942">1942</option>
<option value="1941">1941</option>
<option value="1940">1940</option>
<option value="1939">1939</option>
<option value="1938">1938</option>
<option value="1937">1937</option>
<option value="1936">1936</option>
<option value="1935">1935</option>
<option value="1934">1934</option>
<option value="1933">1933</option>
<option value="1932">1932</option>
<option value="1931">1931</option>
<option value="1930">1930</option>
<option value="1929">1929</option>
<option value="1928">1928</option>
<option value="1927">1927</option>
<option value="1926">1926</option>
<option value="1925">1925</option>
<option value="1924">1924</option>
<option value="1923">1923</option>
<option value="1922">1922</option>
<option value="1921">1921</option>
<option value="1920">1920</option>
<option value="1919">1919</option>
<option value="1918">1918</option>
<option value="1917">1917</option>
<option value="1916">1916</option>
<option value="1915">1915</option>
<option value="1914">1914</option>
<option value="1913">1913</option>
<option value="1912">1912</option>
<option value="1911">1911</option>
<option value="1910">1910</option>
<option value="1909">1909</option>
<option value="1908">1908</option>
<option value="1907">1907</option>
<option value="1906">1906</option>
<option value="1905">1905</option>
<option value="1904">1904</option>
<option value="1903">1903</option>
<option value="1902">1902</option>
<option value="1901">1901</option>
<option value="1900">1900</option>
</select></span>
</div>
<div class="form-group">
<label>Is the other party involved a City Employee?</label>
<div class="form-group">
<label class="radio-inline"><input type="radio" name="participant2_is_city_employee" value="Yes">Yes</label>
<label class="radio-inline"><input type="radio" name="participant2_is_city_employee" value="No">No</label>
<label class="radio-inline"><input type="radio" name="participant2_is_city_employee" value="Unknown">Unknown</label>
</div>
</div>
<div id="participant2_city_agency_show_hide" style="display:none;">
<div class="well well_rb">
<div class="form-group">
<label for="participant2_city_agency">Select City Agency:</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-list"></i></span>
<select class="form-control" id="participant2_city_agency" name="participant2_city_agency">
<option value="" selected="" disabled="">Choose a City Agency </option>
<option value="Administration for Children Services (ACS)">Administration for Children Services (ACS)</option>
<option value="Board of Election (BOE)">Board of Election (BOE)</option>
<option value="Board of Estimate (BDEST)">Board of Estimate (BDEST)</option>
<option value="Board of Standards and Appeals (BSA)">Board of Standards and Appeals (BSA)</option>
<option value="Borough President – Bronx">Borough President – Bronx</option>
<option value="Borough President – Brooklyn">Borough President – Brooklyn</option>
<option value="Borough President – Manhattan">Borough President – Manhattan</option>
<option value="Borough President – Queens">Borough President – Queens</option>
<option value="Borough President – Staten Island">Borough President – Staten Island</option>
<option value="Business Integrity Commission (BIC)">Business Integrity Commission (BIC)</option>
<option value="Campaign Finance Board (CFB)">Campaign Finance Board (CFB)</option>
<option value="City Clerk's Office">City Clerk's Office</option>
<option value="City Council">City Council</option>
<option value="City Marshal">City Marshal</option>
<option value="City Sheriff (Sheriff)">City Sheriff (Sheriff) </option>
<option value="City University of New York (CUNY)">City University of New York (CUNY)</option>
<option value="Civil Service Commission (CSC)">Civil Service Commission (CSC)</option>
<option value="Civilian Complaint Review Board (CCRB)">Civilian Complaint Review Board (CCRB)</option>
<option value="Commission on Human Rights (CCHR)">Commission on Human Rights (CCHR)</option>
<option value="Community Board – Manhattan">Community Board – Manhattan</option>
<option value="Community Board – Brooklyn">Community Board – Brooklyn</option>
<option value="Community Board – Bronx">Community Board – Bronx</option>
<option value="Community Board – Queens">Community Board – Queens</option>
<option value="Community Board – Staten Island">Community Board – Staten Island</option>
<option value="Conflicts of Interest Board (COIB)">Conflicts of Interest Board (COIB)</option>
<option value="Department for the Aging (DFTA)">Department for the Aging (DFTA)</option>
<option value="Department of Buildings (DOB)">Department of Buildings (DOB)</option>
<option value="Department of City Planning (DCP)">Department of City Planning (DCP)</option>
<option value="Department of Citywide Administrative Services (DCAS)">Department of Citywide Administrative Services (DCAS)</option>
<option value="Department of Consumer Affairs (DCA)">Department of Consumer Affairs (DCA)</option>
<option value="Department of Correction (DOC)">Department of Correction (DOC)</option>
<option value="Department of Cultural Affairs (DCLA)">Department of Cultural Affairs (DCLA)</option>
<option value="Department of Design & Construction (DDC)">Department of Design & Construction (DDC)</option>
<option value="Department of Education (DOE)">Department of Education (DOE)</option>
<option value="Department of Environmental Protection (DEP)">Department of Environmental Protection (DEP)</option>
<option value="Department of Finance (DOF)">Department of Finance (DOF)</option>
<option value="Department of Health & Mental Hygiene (DOHMH)">Department of Health & Mental Hygiene (DOHMH)</option>
<option value="Department of Homeless Services (DHS)">Department of Homeless Services (DHS)</option>
<option value="Department of Housing Preservation & Development (HPD)">Department of Housing Preservation & Development (HPD)</option>
<option value="Department of Information Technology & Telecommunications (DoITT)">Department of Information Technology & Telecommunications (DoITT)</option>
<option value="Department of Investigation (DOI)">Department of Investigation (DOI)</option>
<option value="Department of Parks & Recreation (Parks)">Department of Parks & Recreation (Parks)</option>
<option value="Department of Probation (DOP)">Department of Probation (DOP)</option>
<option value="Department of Records & Information Services (DORIS)">Department of Records & Information Services (DORIS)</option>
<option value="Department of Sanitation (DSNY)">Department of Sanitation (DSNY)</option>
<option value="Department of Small Business Services (SBS)">Department of Small Business Services (SBS)</option>
<option value="Department of Transportation (DOT)">Department of Transportation (DOT)</option>
<option value="Department of Youth & Community Development (DYCD)">Department of Youth & Community Development (DYCD)</option>
<option value="Department of Youth & Family Justice (DYFJ)">Department of Youth & Family Justice (DYFJ)</option>
<option value="District Attorney – Manhattan (NYDA)">District Attorney – Manhattan (NYDA)</option>
<option value="District Attorney – Brooklyn (BKDA)">District Attorney – Brooklyn (BKDA)</option>
<option value="District Attorney – Queens (QNDA)">District Attorney – Queens (QNDA)</option>
<option value="District Attorney – Bronx (BXDA)">District Attorney – Bronx (BXDA)</option>
<option value="District Attorney – Richmond (SIDA)">District Attorney – Richmond (SIDA)</option>
<option value="Economic Development Corporation (EDC)">Economic Development Corporation (EDC)</option>
<option value="Emergency Medical Services (EMS)">Emergency Medical Services (EMS)</option>
<option value="Financial Information Services Agency (FISA)">Financial Information Services Agency (FISA)</option>
<option value="Fire Department (FDNY)">Fire Department (FDNY)</option>
<option value="Health and Hospitals Corporation (HHC)">Health and Hospitals Corporation (HHC)</option>
<option value="Human Resources Administration (HRA)">Human Resources Administration (HRA)</option>
<option value="Human Rights Commission (HRC)">Human Rights Commission (HRC)</option>
<option value="Independent Budget Office (IBO)">Independent Budget Office (IBO)</option>
<option value="Landmarks Preservation Commission (LPC) ">Landmarks Preservation Commission (LPC) </option>
<option value="Law Department (LAW)">Law Department (LAW)</option>
<option value="Mayor's Office">Mayor's Office </option>
<option value="New York City Comptroller's Office">New York City Comptroller's Office</option>
<option value="New York City Housing Authority (NYCHA)">New York City Housing Authority (NYCHA)</option>
<option value="New York City Employees Retirement System (NYCERS)">New York City Employees Retirement System (NYCERS)</option>
<option value="New York City School Construction Authority (SCA)">New York City School Construction Authority (SCA)</option>
<option value="Office of the Actuary (NYCOA)">Office of the Actuary (NYCOA)</option>
<option value="Office of Administrative Trials and Hearings (OATH)">Office of Administrative Trials and Hearings (OATH)</option>
<option value="Office of Chief Medical Examiner (OCME)">Office of Chief Medical Examiner (OCME)</option>
<option value="Office of Collective Bargaining (OCB)">Office of Collective Bargaining (OCB)</option>
<option value="Office of Management & Budget (OMB)">Office of Management & Budget (OMB)</option>
<option value="Office of the Mayor (MAYOR)">Office of the Mayor (MAYOR)</option>
<option value="Office of Payroll Management (OPA)">Office of Payroll Management (OPA)</option>
<option value="Police Department (NYPD)">Police Department (NYPD)</option>
<option value="Procurement Policy Board (PPB)">Procurement Policy Board (PPB)</option>
<option value="Public Administrator – New York (PANY)">Public Administrator – New York (PANY)</option>
<option value="Public Administrator – Bronx (PABX)">Public Administrator – Bronx (PABX)</option>
<option value="Public Administrator – Brooklyn (PABK)">Public Administrator – Brooklyn (PABK)</option>
<option value="Public Administrator – Queens (PAQN)">Public Administrator – Queens (PAQN)</option>
<option value="Public Administrator – Richmond (PASI)">Public Administrator – Richmond (PASI)</option>
<option value="Public Advocate – (PUBADV)">Public Advocate – (PUBADV)</option>
<option value="Rent Guidelines Board (RGB)">Rent Guidelines Board (RGB)</option>
<option value="Tax Appeals Tribunal">Tax Appeals Tribunal</option>
<option value="Tax Commission (TC)">Tax Commission (TC)</option>
<option value="Taxi & Limousine Commission (TLC)">Taxi & Limousine Commission (TLC)</option>
</select>
</div>
</div>
<div class="form-group">
<label for="participant2_title">Title (Include Rank and Shield Number if Applicable)</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-question-sign"></i></span>
<input type="text" class="form-control" id="participant2_title" name="participant2_title" placeholder="Enter title" maxlength="75">
</div>
</div>
</div> <!-- wells -->
</div> <!-- participant_city_agency_show_hide-->
<div class="form-group">
<label for="participant2_company_name">Company Name</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-tower"></i></span>
<input type="text" class="form-control" id="participant2_company_name" name="participant2_company_name" placeholder="Enter company name" maxlength="75">
</div>
</div>
<div class="form-group">
<label for="participant2_ein">EIN</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-tower"></i></span>
<input type="text" class="form-control" id="participant2_ein" name="participant2_ein" placeholder="Enter EIN(number only)" maxlength="15">
</div>
</div>
<div class="form-group">
<label>Other Party Involved Address:</label>
<div class="form-group">
<label class="radio-inline"><input type="radio" name="participant2_address_type" value="Home">Home</label>
<label class="radio-inline"><input type="radio" name="participant2_address_type" value="Business">Business</label>
<label class="radio-inline"><input type="radio" name="participant2_address_type" value="Unknown">Unknown</label>
</div>
</div>
<div class="form-group">
<label for="participant2_street_address">Street Address</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-home"></i></span>
<input type="text" class="form-control" id="participant2_street_address" name="participant2_street_address" placeholder="Enter street address" maxlength="50">
</div>
</div>
<div class="form-group">
<label for="participant2_apt_number">Apt#/Room/Floor/Suite</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-home"></i></span>
<input type="text" class="form-control" id="participant2_apt_number" name="participant2_apt_number" placeholder="Enter Apt#/Room/Floor/Suite" maxlength="75">
</div>
</div>
<div class="form-group">
<label for="participant2_city_town">City</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-home"></i></span>
<input type="text" class="form-control" id="participant2_city_town" name="participant2_city_town" placeholder="Enter City" maxlength="50">
</div>
</div>
<div class="form-group">
<label for="participant2_state">State</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-list"></i></span>
<select class="form-control" id="participant2_state" name="participant2_state">
<option value="" selected="" disabled="">Choose a State </option>
<option value="Alabama">Alabama</option>
<option value="Alaska">Alaska</option>
<option value="Arizona">Arizona</option>
<option value="Arkansas">Arkansas</option>
<option value="California">California</option>
<option value="Colorado">Colorado</option>
<option value="Connecticut">Connecticut</option>
<option value="Delaware">Delaware</option>
<option value="District of Columbia">District of Columbia</option>
<option value="Florida">Florida</option>
<option value="Georgia">Georgia</option>
<option value="Hawaii">Hawaii</option>
<option value="Idaho">Idaho</option>
<option value="Illinois">Illinois</option>
<option value="Indiana">Indiana</option>
<option value="Iowa">Iowa</option>
<option value="Kansas">Kansas</option>
<option value="Kentucky">Kentucky</option>
<option value="Louisiana">Louisiana</option>
<option value="Maine">Maine</option>
<option value="Maryland">Maryland</option>
<option value="Massachusetts">Massachusetts</option>
<option value="Michigan">Michigan</option>
<option value="Minnesota">Minnesota</option>
<option value="Mississippi">Mississippi</option>
<option value="Missouri">Missouri</option>
<option value="Montana">Montana</option>
<option value="Nebraska">Nebraska</option>
<option value="Nevada">Nevada</option>
<option value="New Hampshire">New Hampshire</option>
<option value="New Jersey">New Jersey</option>
<option value="New Mexico">New Mexico</option>
<option value="New York">New York</option>
<option value="North Carolina">North Carolina</option>
<option value="North Dakota">North Dakota</option>
<option value="Ohio">Ohio</option>
<option value="Oklahoma">Oklahoma</option>
<option value="Oregon">Oregon</option>
<option value="Pennsylvania">Pennsylvania</option>
<option value="Rhode Island">Rhode Island</option>
<option value="South Carolina">South Carolina</option>
<option value="South Dakota">South Dakota</option>
<option value="Tennessee">Tennessee</option>
<option value="Texas">Texas</option>
<option value="Utah">Utah</option>
<option value="Vermont">Vermont</option>
<option value="Virginia">Virginia</option>
<option value="Washington">Washington</option>
<option value="West Virginia">West Virginia</option>
<option value="Wisconsin">Wisconsin</option>
<option value="Wyoming">Wyoming</option>
</select>
</div>
</div>
<div class="form-group has-feedback">
<label for="participant2_zip_code">Zip Code</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-home"></i></span>
<input type="text" class="form-control" id="participant2_zip_code" name="participant2_zip_code" placeholder="Enter zip code" maxlength="5"
data-bv-field="participant2_zip_code"><i class="form-control-feedback" data-bv-icon-for="participant2_zip_code" style="display: none;"></i>
</div>
<small data-bv-validator="zipCode" data-bv-validator-for="participant2_zip_code" class="help-block" style="display: none;">Please enter a valid zip code or leave it blank</small>
</div>
<div class="form-group">
<label>Primary Phone</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-phone"></i></span>
<input type="text" class="form-control input-medium bfh-phone" data-format=" (ddd) ddd-dddd" id="participant2_primary_phone" name="participant2_primary_phone" maxlength="15">
</div>
</div>
<div class="form-group">
<label>Secondary Phone</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-phone"></i></span>
<input type="text" class="form-control input-medium bfh-phone" data-format=" (ddd) ddd-dddd" id="participant2_secondary_phone" name="participant2_secondary_phone" maxlength="15">
</div>
</div>
<div class="form-group has-feedback">
<label for="participant2_website">Website</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-globe"></i></span>
<input type="text" class="form-control" id="participant2_website" name="participant2_website" placeholder="Enter website" maxlength="300"
data-bv-field="participant2_website"><i class="form-control-feedback" data-bv-icon-for="participant2_website" style="display: none;"></i>
</div>
<small data-bv-validator="uri" data-bv-validator-for="participant2_website" class="help-block" style="display: none;">The website address is not valid</small>
</div>
<div class="form-group has-feedback">
<label for="participant2_email">Email Address</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-envelope"></i></span>
<input type="text" class="form-control" id="participant2_email" name="participant2_email" placeholder="Enter email address" maxlength="75"
data-bv-field="participant2_email"><i class="form-control-feedback" data-bv-icon-for="participant2_email" style="display: none;"></i>
</div>
<small data-bv-validator="emailAddress" data-bv-validator-for="participant2_email" class="help-block" style="display: none;">Please enter a valid email address or leave it blank</small>
</div>
</div> <!-- end of additional_partcipant_show_hide -->
<!-- END of additional participant information-->
</div> <!-- end of well div tag -->
</div> <!-- end of div tag 'participant_show_hide' -->
</div> <!-- end of div tag 'panel body' -->
</div> <!-- end of div tag 'panel' -->
<!-- END of participant information-->
<!-- START of summary of complaint ----------------------------------------------------------------------------------------------------------->
<div class="panel panel-default">
<div class="panel-heading">SUMMARY OF INFORMATION</div>
<div class="panel-body">
<!--
<label>When did the incident occur?</label>
<div class = "form-group">
<label >Date and Time of Incident(mm/dd/yyyy hh:mm a)</label>
<div class='input-group date' id="summary_incident_date" >
<input type='text' class="form-control" name="summary_incident_date" id="summary_incident_date_focus" />
<span class="input-group-addon"><span class="glyphicon glyphicon-calendar"></span></span>
</div>
</div>
-->
<div class="form-group">
<div class="row">
<div class="col-md-12"><label>Date of Incident: (mm/dd/yyyy)</label></div>
</div>
<div class="row">
<div class="col-md-12"><input type="text" id="summary_incident_date_combo" data-format="MM/DD/YYYY" data-template="MM / DD / YYYY" name="summary_incident_date_combo" style="display: none;"><span class="combodate"><select class="month "
style="width: auto;">
<option value=""></option>
<option value="0">01</option>
<option value="1">02</option>
<option value="2">03</option>
<option value="3">04</option>
<option value="4">05</option>
<option value="5">06</option>
<option value="6">07</option>
<option value="7">08</option>
<option value="8">09</option>
<option value="9">10</option>
<option value="10">11</option>
<option value="11">12</option>
</select> / <select class="day " style="width: auto;">
<option value=""></option>
<option value="1">01</option>
<option value="2">02</option>
<option value="3">03</option>
<option value="4">04</option>
<option value="5">05</option>
<option value="6">06</option>
<option value="7">07</option>
<option value="8">08</option>
<option value="9">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
</select> / <select class="year " style="width: auto;">
<option value=""></option>
<option value="2024">2024</option>
<option value="2023">2023</option>
<option value="2022">2022</option>
<option value="2021">2021</option>
<option value="2020">2020</option>
<option value="2019">2019</option>
<option value="2018">2018</option>
<option value="2017">2017</option>
<option value="2016">2016</option>
<option value="2015">2015</option>
<option value="2014">2014</option>
<option value="2013">2013</option>
<option value="2012">2012</option>
<option value="2011">2011</option>
<option value="2010">2010</option>
<option value="2009">2009</option>
<option value="2008">2008</option>
<option value="2007">2007</option>
<option value="2006">2006</option>
<option value="2005">2005</option>
<option value="2004">2004</option>
<option value="2003">2003</option>
<option value="2002">2002</option>
<option value="2001">2001</option>
<option value="2000">2000</option>
<option value="1999">1999</option>
<option value="1998">1998</option>
<option value="1997">1997</option>
<option value="1996">1996</option>
<option value="1995">1995</option>
<option value="1994">1994</option>
<option value="1993">1993</option>
<option value="1992">1992</option>
<option value="1991">1991</option>
<option value="1990">1990</option>
<option value="1989">1989</option>
<option value="1988">1988</option>
<option value="1987">1987</option>
<option value="1986">1986</option>
<option value="1985">1985</option>
<option value="1984">1984</option>
<option value="1983">1983</option>
<option value="1982">1982</option>
<option value="1981">1981</option>
<option value="1980">1980</option>
<option value="1979">1979</option>
<option value="1978">1978</option>
<option value="1977">1977</option>
<option value="1976">1976</option>
<option value="1975">1975</option>
<option value="1974">1974</option>
<option value="1973">1973</option>
<option value="1972">1972</option>
<option value="1971">1971</option>
<option value="1970">1970</option>
<option value="1969">1969</option>
<option value="1968">1968</option>
<option value="1967">1967</option>
<option value="1966">1966</option>
<option value="1965">1965</option>
<option value="1964">1964</option>
<option value="1963">1963</option>
<option value="1962">1962</option>
<option value="1961">1961</option>
<option value="1960">1960</option>
<option value="1959">1959</option>
<option value="1958">1958</option>
<option value="1957">1957</option>
<option value="1956">1956</option>
<option value="1955">1955</option>
<option value="1954">1954</option>
<option value="1953">1953</option>
<option value="1952">1952</option>
<option value="1951">1951</option>
<option value="1950">1950</option>
<option value="1949">1949</option>
<option value="1948">1948</option>
<option value="1947">1947</option>
<option value="1946">1946</option>
<option value="1945">1945</option>
<option value="1944">1944</option>
<option value="1943">1943</option>
<option value="1942">1942</option>
<option value="1941">1941</option>
<option value="1940">1940</option>
<option value="1939">1939</option>
<option value="1938">1938</option>
<option value="1937">1937</option>
<option value="1936">1936</option>
<option value="1935">1935</option>
<option value="1934">1934</option>
<option value="1933">1933</option>
<option value="1932">1932</option>
<option value="1931">1931</option>
<option value="1930">1930</option>
<option value="1929">1929</option>
<option value="1928">1928</option>
<option value="1927">1927</option>
<option value="1926">1926</option>
<option value="1925">1925</option>
<option value="1924">1924</option>
<option value="1923">1923</option>
<option value="1922">1922</option>
<option value="1921">1921</option>
<option value="1920">1920</option>
<option value="1919">1919</option>
<option value="1918">1918</option>
<option value="1917">1917</option>
<option value="1916">1916</option>
<option value="1915">1915</option>
<option value="1914">1914</option>
<option value="1913">1913</option>
<option value="1912">1912</option>
<option value="1911">1911</option>
<option value="1910">1910</option>
<option value="1909">1909</option>
<option value="1908">1908</option>
<option value="1907">1907</option>
<option value="1906">1906</option>
<option value="1905">1905</option>
<option value="1904">1904</option>
<option value="1903">1903</option>
<option value="1902">1902</option>
<option value="1901">1901</option>
<option value="1900">1900</option>
</select></span> </div>
</div>
</div>
<div class="form-group">
<div class="row">
<div class="col-md-12"><label>Time of Incident: (hh:mm)</label></div>
</div>
<div class="row">
<div class="col-md-12"><input type="text" id="summary_incident_time_combo" data-format="h:mm a" data-template="h:mm a" name="summary_incident_time_combo" style="display: none;"><span class="combodate"><select class="hour "
style="width: auto;">
<option value=""></option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select>:<select class="minute " style="width: auto;">
<option value=""></option>
<option value="0">00</option>
<option value="5">05</option>
<option value="10">10</option>
<option value="15">15</option>
<option value="20">20</option>
<option value="25">25</option>
<option value="30">30</option>
<option value="35">35</option>
<option value="40">40</option>
<option value="45">45</option>
<option value="50">50</option>
<option value="55">55</option>
</select> <select class="ampm " style="width: auto;">
<option value=" "> </option>
<option value="am">am</option>
<option value="pm">pm</option>
</select></span> </div>
</div>
</div>
<div class="form-group">
<label>Location of Incident</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-list"></i></span>
<select class="form-control" id="summary_incident_location" name="summary_incident_location">
<option value="" selected="" disabled="">Choose a Location</option>
<option value="Bronx">Bronx</option>
<option value="Brooklyn">Brooklyn</option>
<option value="Manhattan">Manhattan</option>
<option value="Queens">Queens</option>
<option value="Staten Island">Staten Island</option>
<option value="Unknown">Unknown</option>
<option value="Other">Other</option>
</select>
</div>
</div>
<div class="form-group" id="summary_incident_location_other_show_hide" style="display:none;">
<label>Please enter location</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-home"></i></span>
<input type="text" class="form-control" id="summary_incident_location_other" name="summary_incident_location_other" placeholder="Enter location" maxlength="50">
</div>
</div>
<div class="form-group has-feedback">
<label><span class="fieldRequired">*</span>Briefly describe your complaint (If applicable, please include the associated summons or arrest number(s), and the complaint number(s) for any related complaints filed with the Civilian Complaint
Review Board or NYPD Internal Affairs):</label>
<div class="input-group"> <span class="input-group-addon"><i class="glyphicon glyphicon-pencil"></i></span>
<textarea class="form-control" rows="7" id="summary_complaint_description" name="summary_complaint_description" placeholder="Enter complaint description(1000 characters limit)" maxlength="1000"
data-bv-field="summary_complaint_description"></textarea><i class="form-control-feedback" data-bv-icon-for="summary_complaint_description" style="display: none;"></i>
</div>
<div id="textarea_feedback">1000 characters remaining</div>
<small data-bv-validator="stringLength" data-bv-validator-for="summary_complaint_description" class="help-block" style="display: none;">This value is not valid</small><small data-bv-validator="notEmpty"
data-bv-validator-for="summary_complaint_description" class="help-block" style="display: none;">Please enter a complaint description(max of 1000 chars)</small>
</div>
<div class="well">
<p>If you do not wish to submit this form electronically, you may click
<a href="./misc/doi-complaint-form.pdf" target="_blank" class="myToolTip" data-toggle="tooltip" data-placement="top" data-html="true" title="" data-original-title="<span class='myToolTipBold'>PLEASE BE ADVISED</span>: If you select the 'Click Here' option, you will lose any information typed above. You will be re-directed to a fillable PDF form that you will need to complete, print and send to DOI. If you wish to continue please click HERE.">HERE</a>
to complete a form to submit via fax or mail to the address below: </p>
<br>
<div class="col-xs-offset-3"> Department of Investigation - Complaint Unit<br> City of New York<br> 180 Maiden Lane - 16th Floor<br> New York, NY 10038<br> 212-825-2504 (Fax)<br>
</div>
<br>
<p><strong>Notification Disclaimer:</strong><br> Communications made through this electronic mail and message system shall in no way be deemed to constitute legal notice to the City of New York or any of its agencies, officers, employees,
agents, or representatives, with respect to any existing or potential claim or cause of action against the City or any of its agencies, officers, employees, agents, or representatives, where notice to the City is required by any federal,
state or local laws, rules, or regulations.</p>
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</form>Text Content
NEW YORK CITY DEPARTMENT OF INVESTIGATION ONLINE COMPLAINT FORM YOUR INFORMATION All fields with an asterisk * are required, but any additional information you can provide will help us to process your complaint. *How did you learn about DOI? Advertisements Corruption Lecture Internet Family/Friend Please select an option *Are you a City Employee? Yes No Please select an option Select City Agency Choose a City Agency Administration for Children Services (ACS) Board of Election (BOE) Board of Estimate (BDEST) Board of Standards and Appeals (BSA) Borough President – Bronx Borough President – Brooklyn Borough President – Manhattan Borough President – Queens Borough President – Staten Island Business Integrity Commission (BIC) Campaign Finance Board (CFB) City Clerk's Office City Council City Marshal City Sheriff (Sheriff) City University of New York (CUNY) Civil Service Commission (CSC) Civilian Complaint Review Board (CCRB) Commission on Human Rights (CCHR) Community Board – Manhattan Community Board – Brooklyn Community Board – Bronx Community Board – Queens Community Board – Staten Island Conflicts of Interest Board (COIB) Department for the Aging (DFTA) Department of Buildings (DOB) Department of City Planning (DCP) Department of Citywide Administrative Services (DCAS) Department of Consumer Affairs (DCA) Department of Correction (DOC) Department of Cultural Affairs (DCLA) Department of Design & Construction (DDC) Department of Education (DOE) Department of Environmental Protection (DEP) Department of Finance (DOF) Department of Health & Mental Hygiene (DOHMH) Department of Homeless Services (DHS) Department of Housing Preservation & Development (HPD) Department of Information Technology & Telecommunications (DoITT) Department of Investigation (DOI) Department of Parks & Recreation (Parks) Department of Probation (DOP) Department of Records & Information Services (DORIS) Department of Sanitation (DSNY) Department of Small Business Services (SBS) Department of Transportation (DOT) Department of Youth & Community Development (DYCD) Department of Youth & Family Justice (DYFJ) District Attorney – Manhattan (NYDA) District Attorney – Brooklyn (BKDA) District Attorney – Queens (QNDA) District Attorney – Bronx (BXDA) District Attorney – Richmond (SIDA) Economic Development Corporation (EDC) Emergency Medical Services (EMS) Financial Information Services Agency (FISA) Fire Department (FDNY) Health and Hospitals Corporation (HHC) Human Resources Administration (HRA) Human Rights Commission (HRC) Independent Budget Office (IBO) Landmarks Preservation Commission (LPC) Law Department (LAW) Mayor's Office New York City Comptroller's Office New York City Housing Authority (NYCHA) New York City Employees Retirement System (NYCERS) New York City School Construction Authority (SCA) Office of the Actuary (NYCOA) Office of Administrative Trials and Hearings (OATH) Office of Chief Medical Examiner (OCME) Office of Collective Bargaining (OCB) Office of Management & Budget (OMB) Office of the Mayor (MAYOR) Office of Payroll Management (OPA) Police Department (NYPD) Procurement Policy Board (PPB) Public Administrator – New York (PANY) Public Administrator – Bronx (PABX) Public Administrator – Brooklyn (PABK) Public Administrator – Queens (PAQN) Public Administrator – Richmond (PASI) Public Advocate – (PUBADV) Rent Guidelines Board (RGB) Tax Appeals Tribunal Tax Commission (TC) Taxi & Limousine Commission (TLC) Title (Include Rank and Shield Number if Applicable) You may make your complaint anonymously; however, to help DOI process your complaint, please consider providing a way for us to contact you if there are follow-up questions. *Do you wish to remain anonymous? Yes No Please select an option *First Name Please enter your first nameThis value is not valid *Last Name Please enter your last nameThis value is not valid Company Name This value is not valid Address: Home Business Street Address This value is not valid Apt#/Room/Floor/Suite This value is not valid City This value is not valid State Choose a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Please enter a valid zip code or leave it blankThis value is not valid Primary Phone Please enter a valid phone number with area codeThis value is not valid Secondary Phone Please enter a valid phone number with area codeThis value is not valid Email Address Please enter a valid email address or leave it blankPlease enter a valid email address or leave it blankThis value is not valid What is the best way to contact you? Primary Phone Secondary Phone Email SUBJECT OF YOUR COMPLAINT Please enter as much information as you can regarding the primary person or company allegedly involved in the complaint. The subject is a: Person Company Unknown *First Name Please enter subject first name or type 'unknown'This value is not valid *Last Name Please enter subject last name or type 'unknown'This value is not valid Nickname This value is not valid Date of Birth 010203040506070809101112 01020304050607080910111213141516171819202122232425262728293031 20242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900 *Is the subject a City Employee? Yes No Unknown Please select an option Select City Agency Choose a City Agency Administration for Children Services (ACS) Board of Election (BOE) Board of Estimate (BDEST) Board of Standards and Appeals (BSA) Borough President – Bronx Borough President – Brooklyn Borough President – Manhattan Borough President – Queens Borough President – Staten Island Business Integrity Commission (BIC) Campaign Finance Board (CFB) City Clerk's Office City Council City Marshal City Sheriff (Sheriff) City University of New York (CUNY) Civil Service Commission (CSC) Civilian Complaint Review Board (CCRB) Commission on Human Rights (CCHR) Community Board – Manhattan Community Board – Brooklyn Community Board – Bronx Community Board – Queens Community Board – Staten Island Conflicts of Interest Board (COIB) Department for the Aging (DFTA) Department of Buildings (DOB) Department of City Planning (DCP) Department of Citywide Administrative Services (DCAS) Department of Consumer Affairs (DCA) Department of Correction (DOC) Department of Cultural Affairs (DCLA) Department of Design & Construction (DDC) Department of Education (DOE) Department of Environmental Protection (DEP) Department of Finance (DOF) Department of Health & Mental Hygiene (DOHMH) Department of Homeless Services (DHS) Department of Housing Preservation & Development (HPD) Department of Information Technology & Telecommunications (DoITT) Department of Investigation (DOI) Department of Parks & Recreation (Parks) Department of Probation (DOP) Department of Records & Information Services (DORIS) Department of Sanitation (DSNY) Department of Small Business Services (SBS) Department of Transportation (DOT) Department of Youth & Community Development (DYCD) Department of Youth & Family Justice (DYFJ) District Attorney – Manhattan (NYDA) District Attorney – Brooklyn (BKDA) District Attorney – Queens (QNDA) District Attorney – Bronx (BXDA) District Attorney – Richmond (SIDA) Economic Development Corporation (EDC) Emergency Medical Services (EMS) Financial Information Services Agency (FISA) Fire Department (FDNY) Health and Hospitals Corporation (HHC) Human Resources Administration (HRA) Human Rights Commission (HRC) Independent Budget Office (IBO) Landmarks Preservation Commission (LPC) Law Department (LAW) Mayor's Office New York City Comptroller's Office New York City Housing Authority (NYCHA) New York City Employees Retirement System (NYCERS) New York City School Construction Authority (SCA) Office of the Actuary (NYCOA) Office of Administrative Trials and Hearings (OATH) Office of Chief Medical Examiner (OCME) Office of Collective Bargaining (OCB) Office of Management & Budget (OMB) Office of the Mayor (MAYOR) Office of Payroll Management (OPA) Police Department (NYPD) Procurement Policy Board (PPB) Public Administrator – New York (PANY) Public Administrator – Bronx (PABX) Public Administrator – Brooklyn (PABK) Public Administrator – Queens (PAQN) Public Administrator – Richmond (PASI) Public Advocate – (PUBADV) Rent Guidelines Board (RGB) Tax Appeals Tribunal Tax Commission (TC) Taxi & Limousine Commission (TLC) Title (Include Rank and Shield Number if Applicable) *Company Name Please enter company nameThis value is not valid EIN This value is not valid *Subject Address: Home Business Unknown Please select an option Street Address This value is not valid Apt#/Room/Floor/Suite This value is not valid City This value is not valid State Choose a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Please enter a valid zip code or leave it blankThis value is not valid Primary Phone This value is not valid Secondary Phone This value is not valid Website The website address is not validThis value is not valid Email Address Please enter a valid email address or leave it blankThis value is not valid Are there any additional addresses involved in this complaint? Yes No *Subject Address: Home Business Unknown Please select an option Street Address Apt#/Room/Floor/Suite City State Choose a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Please enter a valid zip code or leave it blank Primary Phone Secondary Phone Website The website address is not valid Email Address Please enter a valid email address or leave it blank *Are there any additional subjects involved in this complaint? Yes No Please select an option The subject is a: Person Company Unknown *First Name Please enter subject first name or type 'unknown' *Last Name Please enter subject last name or type 'unknown' Nickname Date of Birth 010203040506070809101112 01020304050607080910111213141516171819202122232425262728293031 20242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900 *Is the subject a City Employee? Yes No Unknown Please select an option Select Agency: Choose a City Agency Administration for Children Services (ACS) Board of Election (BOE) Board of Estimate (BDEST) Board of Standards and Appeals (BSA) Borough President – Bronx Borough President – Brooklyn Borough President – Manhattan Borough President – Queens Borough President – Staten Island Business Integrity Commission (BIC) Campaign Finance Board (CFB) City Clerk's Office City Council City Marshal City Sheriff (Sheriff) City University of New York (CUNY) Civil Service Commission (CSC) Civilian Complaint Review Board (CCRB) Commission on Human Rights (CCHR) Community Board – Manhattan Community Board – Brooklyn Community Board – Bronx Community Board – Queens Community Board – Staten Island Conflicts of Interest Board (COIB) Department for the Aging (DFTA) Department of Buildings (DOB) Department of City Planning (DCP) Department of Citywide Administrative Services (DCAS) Department of Consumer Affairs (DCA) Department of Correction (DOC) Department of Cultural Affairs (DCLA) Department of Design & Construction (DDC) Department of Education (DOE) Department of Environmental Protection (DEP) Department of Finance (DOF) Department of Health & Mental Hygiene (DOHMH) Department of Homeless Services (DHS) Department of Housing Preservation & Development (HPD) Department of Information Technology & Telecommunications (DoITT) Department of Investigation (DOI) Department of Parks & Recreation (Parks) Department of Probation (DOP) Department of Records & Information Services (DORIS) Department of Sanitation (DSNY) Department of Small Business Services (SBS) Department of Transportation (DOT) Department of Youth & Community Development (DYCD) Department of Youth & Family Justice (DYFJ) District Attorney – Manhattan (NYDA) District Attorney – Brooklyn (BKDA) District Attorney – Queens (QNDA) District Attorney – Bronx (BXDA) District Attorney – Richmond (SIDA) Economic Development Corporation (EDC) Emergency Medical Services (EMS) Financial Information Services Agency (FISA) Fire Department (FDNY) Health and Hospitals Corporation (HHC) Human Resources Administration (HRA) Human Rights Commission (HRC) Independent Budget Office (IBO) Landmarks Preservation Commission (LPC) Law Department (LAW) Mayor's Office New York City Comptroller's Office New York City Housing Authority (NYCHA) New York City Employees Retirement System (NYCERS) New York City School Construction Authority (SCA) Office of the Actuary (NYCOA) Office of Administrative Trials and Hearings (OATH) Office of Chief Medical Examiner (OCME) Office of Collective Bargaining (OCB) Office of Management & Budget (OMB) Office of the Mayor (MAYOR) Office of Payroll Management (OPA) Police Department (NYPD) Procurement Policy Board (PPB) Public Administrator – New York (PANY) Public Administrator – Bronx (PABX) Public Administrator – Brooklyn (PABK) Public Administrator – Queens (PAQN) Public Administrator – Richmond (PASI) Public Advocate – (PUBADV) Rent Guidelines Board (RGB) Tax Appeals Tribunal Tax Commission (TC) Taxi & Limousine Commission (TLC) Title (Include Rank and Shield Number if Applicable) *Company Name Please enter company name EIN *Subject Address: Home Business Unknown Please select an option Street Address Apt#/Room/Floor/Suite City State Choose a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Please enter a valid zip code or leave it blank Primary Phone Secondary Phone Website The website address is not valid Email Address Please enter a valid email address or leave it blank Are there any additional addresses involved in this complaint? Yes No *Subject Address: Home Business Unknown Please select an option Street Address Apt#/Room/Floor/Suite City State Choose a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Please enter a valid zip code or leave it blank Primary Phone Secondary Phone Website The website address is not valid Email Address Please enter a valid email address or leave it blank WITNESS / VICTIM / OTHER COMPANY INFORMATION *Are there any witnesses, victims, and/or other companies involved in this complaint? Yes No Please select an option *The other party involved is a: Witness Victim Other Company Please select an option First Name Last Name Nickname Date of Birth 010203040506070809101112 01020304050607080910111213141516171819202122232425262728293031 20242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900 Is the other party involved a City Employee? Yes No Unknown Select City Agency: Choose a City Agency Administration for Children Services (ACS) Board of Election (BOE) Board of Estimate (BDEST) Board of Standards and Appeals (BSA) Borough President – Bronx Borough President – Brooklyn Borough President – Manhattan Borough President – Queens Borough President – Staten Island Business Integrity Commission (BIC) Campaign Finance Board (CFB) City Clerk's Office City Council City Marshal City Sheriff (Sheriff) City University of New York (CUNY) Civil Service Commission (CSC) Civilian Complaint Review Board (CCRB) Commission on Human Rights (CCHR) Community Board – Manhattan Community Board – Brooklyn Community Board – Bronx Community Board – Queens Community Board – Staten Island Conflicts of Interest Board (COIB) Department for the Aging (DFTA) Department of Buildings (DOB) Department of City Planning (DCP) Department of Citywide Administrative Services (DCAS) Department of Consumer Affairs (DCA) Department of Correction (DOC) Department of Cultural Affairs (DCLA) Department of Design & Construction (DDC) Department of Education (DOE) Department of Environmental Protection (DEP) Department of Finance (DOF) Department of Health & Mental Hygiene (DOHMH) Department of Homeless Services (DHS) Department of Housing Preservation & Development (HPD) Department of Information Technology & Telecommunications (DoITT) Department of Investigation (DOI) Department of Parks & Recreation (Parks) Department of Probation (DOP) Department of Records & Information Services (DORIS) Department of Sanitation (DSNY) Department of Small Business Services (SBS) Department of Transportation (DOT) Department of Youth & Community Development (DYCD) Department of Youth & Family Justice (DYFJ) District Attorney – Manhattan (NYDA) District Attorney – Brooklyn (BKDA) District Attorney – Queens (QNDA) District Attorney – Bronx (BXDA) District Attorney – Richmond (SIDA) Economic Development Corporation (EDC) Emergency Medical Services (EMS) Financial Information Services Agency (FISA) Fire Department (FDNY) Health and Hospitals Corporation (HHC) Human Resources Administration (HRA) Human Rights Commission (HRC) Independent Budget Office (IBO) Landmarks Preservation Commission (LPC) Law Department (LAW) Mayor's Office New York City Comptroller's Office New York City Housing Authority (NYCHA) New York City Employees Retirement System (NYCERS) New York City School Construction Authority (SCA) Office of the Actuary (NYCOA) Office of Administrative Trials and Hearings (OATH) Office of Chief Medical Examiner (OCME) Office of Collective Bargaining (OCB) Office of Management & Budget (OMB) Office of the Mayor (MAYOR) Office of Payroll Management (OPA) Police Department (NYPD) Procurement Policy Board (PPB) Public Administrator – New York (PANY) Public Administrator – Bronx (PABX) Public Administrator – Brooklyn (PABK) Public Administrator – Queens (PAQN) Public Administrator – Richmond (PASI) Public Advocate – (PUBADV) Rent Guidelines Board (RGB) Tax Appeals Tribunal Tax Commission (TC) Taxi & Limousine Commission (TLC) Title (Include Rank and Shield Number if Applicable) Company Name EIN Other Party Involved Address: Home Business Unknown Street Address Apt#/Room/Floor/Suite City State Choose a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Please enter a valid zip code or leave it blank Primary Phone Secondary Phone Website The website address is not valid Email Address Please enter a valid email address or leave it blank Are there any additional witnesses, victims, and/or other companies involved in this complaint? Yes No *The other party involved is a: Witness Victim Other Company Please select an option First Name Last Name Date of Birth 010203040506070809101112 01020304050607080910111213141516171819202122232425262728293031 20242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900 Is the other party involved a City Employee? Yes No Unknown Select City Agency: Choose a City Agency Administration for Children Services (ACS) Board of Election (BOE) Board of Estimate (BDEST) Board of Standards and Appeals (BSA) Borough President – Bronx Borough President – Brooklyn Borough President – Manhattan Borough President – Queens Borough President – Staten Island Business Integrity Commission (BIC) Campaign Finance Board (CFB) City Clerk's Office City Council City Marshal City Sheriff (Sheriff) City University of New York (CUNY) Civil Service Commission (CSC) Civilian Complaint Review Board (CCRB) Commission on Human Rights (CCHR) Community Board – Manhattan Community Board – Brooklyn Community Board – Bronx Community Board – Queens Community Board – Staten Island Conflicts of Interest Board (COIB) Department for the Aging (DFTA) Department of Buildings (DOB) Department of City Planning (DCP) Department of Citywide Administrative Services (DCAS) Department of Consumer Affairs (DCA) Department of Correction (DOC) Department of Cultural Affairs (DCLA) Department of Design & Construction (DDC) Department of Education (DOE) Department of Environmental Protection (DEP) Department of Finance (DOF) Department of Health & Mental Hygiene (DOHMH) Department of Homeless Services (DHS) Department of Housing Preservation & Development (HPD) Department of Information Technology & Telecommunications (DoITT) Department of Investigation (DOI) Department of Parks & Recreation (Parks) Department of Probation (DOP) Department of Records & Information Services (DORIS) Department of Sanitation (DSNY) Department of Small Business Services (SBS) Department of Transportation (DOT) Department of Youth & Community Development (DYCD) Department of Youth & Family Justice (DYFJ) District Attorney – Manhattan (NYDA) District Attorney – Brooklyn (BKDA) District Attorney – Queens (QNDA) District Attorney – Bronx (BXDA) District Attorney – Richmond (SIDA) Economic Development Corporation (EDC) Emergency Medical Services (EMS) Financial Information Services Agency (FISA) Fire Department (FDNY) Health and Hospitals Corporation (HHC) Human Resources Administration (HRA) Human Rights Commission (HRC) Independent Budget Office (IBO) Landmarks Preservation Commission (LPC) Law Department (LAW) Mayor's Office New York City Comptroller's Office New York City Housing Authority (NYCHA) New York City Employees Retirement System (NYCERS) New York City School Construction Authority (SCA) Office of the Actuary (NYCOA) Office of Administrative Trials and Hearings (OATH) Office of Chief Medical Examiner (OCME) Office of Collective Bargaining (OCB) Office of Management & Budget (OMB) Office of the Mayor (MAYOR) Office of Payroll Management (OPA) Police Department (NYPD) Procurement Policy Board (PPB) Public Administrator – New York (PANY) Public Administrator – Bronx (PABX) Public Administrator – Brooklyn (PABK) Public Administrator – Queens (PAQN) Public Administrator – Richmond (PASI) Public Advocate – (PUBADV) Rent Guidelines Board (RGB) Tax Appeals Tribunal Tax Commission (TC) Taxi & Limousine Commission (TLC) Title (Include Rank and Shield Number if Applicable) Company Name EIN Other Party Involved Address: Home Business Unknown Street Address Apt#/Room/Floor/Suite City State Choose a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Please enter a valid zip code or leave it blank Primary Phone Secondary Phone Website The website address is not valid Email Address Please enter a valid email address or leave it blank SUMMARY OF INFORMATION Date of Incident: (mm/dd/yyyy) 010203040506070809101112 / 01020304050607080910111213141516171819202122232425262728293031 / 20242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900 Time of Incident: (hh:mm) 123456789101112:000510152025303540455055 ampm Location of Incident Choose a Location Bronx Brooklyn Manhattan Queens Staten Island Unknown Other Please enter location *Briefly describe your complaint (If applicable, please include the associated summons or arrest number(s), and the complaint number(s) for any related complaints filed with the Civilian Complaint Review Board or NYPD Internal Affairs): 1000 characters remaining This value is not validPlease enter a complaint description(max of 1000 chars) If you do not wish to submit this form electronically, you may click HERE to complete a form to submit via fax or mail to the address below: Department of Investigation - Complaint Unit City of New York 180 Maiden Lane - 16th Floor New York, NY 10038 212-825-2504 (Fax) Notification Disclaimer: Communications made through this electronic mail and message system shall in no way be deemed to constitute legal notice to the City of New York or any of its agencies, officers, employees, agents, or representatives, with respect to any existing or potential claim or cause of action against the City or any of its agencies, officers, employees, agents, or representatives, where notice to the City is required by any federal, state or local laws, rules, or regulations. 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