File Complaint

Your Name

Home Phone

Cell Phone

Home Address

City

State

Zip

Primary Contact Email

Name of Business/Entity/Location *

Type of Business/Entity/Location (e.g., restaurant, bar, salon, theater, office, park etc.) *

Street Address *

City *

State *

Zip *

County *

Phone (if known)

Website (if known)

Date *

Time *

Estimated Number of Individuals Observed at Location *

Details/Description *

Please validate the business address.

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