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Environmental Health Complaints/Request For Appointment

2. Restaurant or other establishment name or description.

4. Establishment location/address

6. Enter detailed information about any complaints, comments or questions you may have or why you would like to schedule an appointment.

8. Please provide contact information so that we may contact you in case we have questions about the complaint or issue you need to address. If you wish to remain anonymous please indicate below. Please note that if a public records request is submitted we may be required to provide the completed form to the requester.

   Please provide contact information so that we may contact you in case we have questions about the complaint or issue you need to address. If you wish to remain anonymous please indicate below. Please note that if a public records request is submitted we may be required to provide the completed form to the requester.

10. First Name

11. Last Name

13. Address1

15. Address2

17. City

18. State

19. Zip

21. Phone Number

22. Alt Phone Number

24. Email Address

26. Date and time of the incident
    Date and time of the incident

    Date and time of the incident

28. Do you wish to remain Anonymous?

    1. No
    2. Yes

Leave This Blank:


30. 1. Receive an email copy of this form.
31. Email address

    This field is not part of the form submission.

32. Submit

* indicates a required field