RIDE ALONG REQUEST - AMOEBA TAMPAN

[Amoeba Tampan]

RIDE ALONG REQUEST

1. PERSONAL INFORMATION

• 1.1 FULL NAME

• • FIRST NAME:[Amoeba]
    MIDDLE NAME:
    LAST NAME:[Tampan]

2. DATE OF BIRTH

• • DOB(DD/MM/YYYY):[25/05/2005]
    Nationality:[Indonesia]
    Gender:[MALE]

By signing this document, I acknowledge that the opportunity to participate in the Los Santos
Police Department Ride-Along Program is a privilege and that the assigned officer, Chief of
Police, or his designee can discontinue my participation in the ride-along program at any
time.

Sincerely yours,
your signature
[Amoeba Tampan]