Drive Off Form/Failure to Pay

Date
MM slash DD slash YYYY
Time

:
Store Number*
Dollar Amount of Drive-off*
Is there a video of the incident available?
Visability
Physical Description
Driver
Passengers
How many passengers, male and femaie, and distinguishing characteristics of passengers:
List number of male and female passengers and any distinguishing characteristics of each.
Race
Hair Color
Hair Length
Eye Color
Height (approximately)
Weight (approximately)
Clothes (color shorts, jeans, uniform, etc)
Any Distinguishing Clothes (jacket, hats, etc.)
Other Physical Characteristics (facial hair, tattoos, etc.)
Vehicle Description
License Number
State
Make (Chevy, Ford, etc.)
Model
Color
Misc. Vehicle Description
Direction Traveled After Leaving Station
Describe Incident (what happened)
What Part of Store Were You In?
Police Called?
Department
Incident Report #
Officer's Name
The Above Information is Correct, to the Best of my Knowledge:
Employee Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Employee Signature

Save and Continue Later

Physical Description