SMC Pull Over Form

1
What club are you a member of?* This field is required.If none, use Independant.
2
Name* This field is required.of person who was pulled over.
First Name
Last Name
3
Phone Numberof person who was pulled over.
Please enter a valid phone number.
4
Emailof person who was pulled over.
example@example.com
5
Date* This field is required.the pull over occured
Date
Month
Day
Year
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
AM
AM
PM
6
Where you attending an event or run?
Yes
No
7
Where you attending an event or run?
YESNO
8
Was this your only Pull Over today?
YESNO
9
Was this your only Pull Over today?
Yes
No
10
Description of Pull Over* This field is required.
11
Reason Given for the Pull Over* This field is required.
12
How many riders were pulled over?
13
Number of police vehicles involved
14
Number of police officers involved
15
Where any charges laid? If yes, what charges?If yes, please list.
16
Where any warnings issued? If yes, please list.
17
Where photos or video taken of the following, by the officers?
Riders
Plates or Licenses
Bike
Colours
18
Were licenses and insurance coverage checked, by the officers?
Yes
No
19
Were licenses and insurance coverage checked, by the officers?
YESNO
20
Were drug or alcohol tests administered, by the officers?
YESNO
21
Were drug or alcohol tests administered, by the officers?
Yes
No
22
What were the officers like to deal with?
Friendly
Aggressive
Abusive
Other
23
Officers Name(s)
24
Officers Badge Number(s)
25
Did you take pictures or video of the stop?
Yes
No
26
Did you take pictures or video of the stop?
YESNO
27
Was it a safe pull over?
YESNO
28
Was it a safe pull over?
Yes
No
29
Where were you pulled over?
City, Street, Address or GPS Coordinates
30
Direction of travel
North
South
East
West
31
Road conditions
Dry
Wet
Icy
Snowy
32
Traffic flow
No traffic
Light traffic
Moderate traffic
Heavy traffic
33
Did you take any notes at the time of the pullover?
YESNO
34
Did you take any notes at the time of the pullover?
Yes
No
35
Please attach any pictures, videos or notes you are willing to share here
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
36
Please tell us in your own words, what happened, how it made you FEEL, and any other information that you think would be helpful.* This field is required.
37
Please verify that you are human* This field is required.
38
Should be Empty: