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Health/Food Complaints

2. Location of Occurance*

   If no address, try to describe location or facility.

4. Complainants First Name*

5. Complainants Last Name*

7. Address1

9. City*

10. State*

11. Zip*

13. Complainants E-Mail address or Phone Number*

    In case we require more information

15. Property Involved*

    1. Restaurant
    2. Child Day Care
    3. Adult Day Care
    4. Foster Home
    5. School

16. Nuisance Complaint*

    1. Food Complaint
    2. Site Conditions
    3. Illness
    4. Insect Complaint
    5. Other

17. Please specify other

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19. 1. Receive an email copy of this form.
20. Email address

    This field is not part of the form submission.

21. Submit Submit and Print

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