Unsafe Driver Dashcam Video Sample Reporting Page

THIS PAGE IS JUST A SAMPLE FORM. TO REPORT AN UNSAFE DRIVER, PLEASE GO TO www.ReportingDriver.org

Sample Form

Your Information

This Form is only form traffic offenses with video evidence. It is NOT for submitting footage of Road Traffic Collisions or parking offences.

It allows members of the public to report driving offences by filling out a form and uploading video evidence they have captured.

You may be contacted about this report and asked to be a witness if any legal proceedings occur as a result of this report.

Last Name

First Name

Address

City/Town

State

Zipe Code

Phone

I am willing to attend Court and give evidence in relation to this matter.

Yes

I confirm this statement is true to the best of my knowledge and belief and I make it knowing that if it is tendered in evidence I shall be liable to prosecution if I have wilfully stated in it anything which I know to be false, or do not believe to be true

I Agree

Time of offense

Date of offense

City/State of offense

Type of Offense

Offender License Plate

State Of License Plate

Make / Model Of vehicle

Color of Vehicle

In your own words, describe what happened including as much detail as possible

(Option 1) Provide Video Link

(Option 2) Upload video File

Maximum file size: 20MB

If you are human, leave this field blank.