Business Complaint Form

Your Information (in case we need to follow up for additional information)
Your Name Your Name * First Last
Your Email *
Home Phone Home Phone - ### - ### ####
Cell Phone Cell Phone - ### - ### ####
Your Address Your Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
About the Business/Entity/Location

To identify the business/entity/location in potential violation, please be specific in your description and include as much information as possible
Name of Business/Entity/Location *
Type of Business/Entity/Location (e.g., restaurant, bar, salon, theater, office, park etc.) *
Business Address Business Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Number (if known) Phone Number (if known) - ### - ### ####
Website (if known)
Date of Incident/Violation Date of Incident/Violation * / MM / DD YYYY
Time of Incident/Violation *
Additional Details *
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