Form Center

2. Name
3. Email
5. Phone*
6. Complaint Property*
7. Zip Code*
   -- Select One --750337503475035
9. Complaint Property Address*
11. Type of Violation*

    1. Animal(s)
    2. Employee(s)
    3. Foodborne illness
    4. Illegal food sales
    5. Imminent health hazard

    1. Improperly cooked food
    2. Insects
    3. No health permit
    4. Odor, air / water

    1. Rodents
    2. Stagnant water
    3. Unsanitary conditions
    4. Other (list below)
13. Additional Information
Leave This Blank:


15. 1. Receive an email copy of this form.
16. Email address

    This field is not part of the form submission.

17. Submit

* indicates a required field