6=R14—' B DEPARTMENT OF JORT:-t imi ARRESTING OFFICER WILL O0PPLETE ALL PLOOIRED DATA ON THIS FORM PR:08.JC COMMITT"G TO MCC/MDCs. Re .40/4/ First VG \T efreit Name: Last Race ( heck) 8 W A I 5e4 (Check) Ethnic Origin (Check F;Ig I TEIN namem JEFFREY mon. um. EDWARD H, 6' 0" Kt 185 GRY