Form Eeo-4 - State And Local Government Information Page 4

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REMARKS (List National Crime Information Center (NCIC) number 
assigned to any Criminal Justice Agencies whose data 
are included in this report) 
***LIST AGENCIES INCLUDED ON THIS FORM*** 
CERTIFICATION.  I certify that the information given in this report is correct and true to the best of my knowledge and was reported in 
accordance with accompanying instructions. (Willfully false statements on this report are punishable by law, US Code, Title 18, Section 
1001.) 
NAME OF PERSON TO CONTACT REGARDING THIS FORM 
TITLE 
ADDRESS (Number and Street, City, State, Zip Code) 
TELEPHONE NUMBER 
extension: 
FAX NUMBER 
TYPED NAME/TITLE OF AUTHORIZED OFFICIAL 
SIGNATURE 
DATE 
E­MAIL 
EEOC  FORM 164, FEB 97 (Previous Editions Obsolete) 
 
 
 
 
 
 
 
       PAGE 4

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