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2. This form is for filing a compliment regarding an officer’s or other employee's, conduct or the level of service, provided by the Purcellville Police Department. Information submitted on this form will be sent via email to the following PPD staff members: Chief, Deputy Chief, Operations Lieutenant, Administrative Lieutenant, and the Records Manager. * Indicates Required Field/Information
4. Your Information:
6. First Name*
7. Middle Initial
8. Last Name*
10. Address1
12. Address2
14. City
15. State
16. Zip
18. Email
20. Summary of Interaction:
22. Please enter the Officer(s)/Employee(s) names.
24. Location:*
25. Date and Time
    Date and Time

    Date and Time
27. Please describe the interaction.*
29. *Approval for Use on PPD/Town Website The Town of Purcellville would like to share your compliment with the community as part of our Compliments Corner:
30. Approval for Use on PPD/Town Website*
    -- Select One --Please Share. Your personal information (Name/e-mail/Address etc.) will be removed. Please do not Share on the Website.
32. Please be aware that information submitted through the Town of Purcellville Government website is considered a Public Record under the Virginia Public Records Act, and may be subject to release by the Town in response to a request made under the Virginia Freedom of Information Act.
34. Do not submit any unsolicited personally identifiable information including (but not limited to) your: (1) social security number; (2) driver's license number; (3) bank account numbers; (4) credit or debit card numbers; (5) personal identification numbers (PIN); (6) electronic identification codes; (7) automated or electronic signatures; or (8) passwords; or (9) any other numbers or information that can be used to access your assets, obtain identification, act as identification, or obtain goods or services.
Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit Submit and Print

* indicates a required field