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2. Our Specialists may need to contact you for additional information.
   
   Complainant information is confidential, unless a subpoena requests the complaint form be submitted for legal process.
4. Name*
6. Phone*
7. Email*
9. Street Address*
11. Address Line 2
13. City
14. State
15. Zip
19. Complaint Information
    Please be as detailed as possible when filling out complaint information. This will help our Specialists respond quickly and appropriately.
21. Complaint Type*
    -- Select One --Chemical SpillFood PoisoningGarbagePublic Swimming Pool/SpaRestaurant or Food FacilityTattoo or Body Art ShopSewage on the GroundSub-Standard HousingOther

    Choose the option that best describes your complaint.
23. Complaint*
25. Attach Photos
27. Complaint Business Name, if applicable
29. Complaint Address
31. Address Line 2
33. City
34. State
35. Zip
37. Complaint Phone Number
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39. 1. Receive an email copy of this form.
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