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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.
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