Citizen Complaint Form - Town Of Florence printable pdf download

Citizen Complaint Form - Town Of Florence

TOWN OF FLORENCE

CITIZEN COMPLAINT FORM

PO Box 2670, 775 North Main Street, Florence, AZ 85132

General Office Hours: Monday through Friday 8:00 a.m. to 5:00 p.m.

Telephone: (520) 868-7500 / Fax: (520) 868-7564

E-mail: lisa.garcia@florenceaz.gov

Web Site

PLEASE PRINT:

1. YOUR NAME:

2. YOUR ADDRESS:

3. YOUR DAYTIME TELEPHONE NUMBER:

4. YOUR EVENING TELEPHONE NUMBER:

5. IS THE COMPLAINT REGARDING:

A TOWN POLICY OR PROCEDURE

YES

(If so, skip to question #10)

A TOWN EMPLOYEE

YES

(If so, please complete the rest of the form)

6. DATE OF THE INCIDENT OR COMPLAINT:

7. TIME OF THE INCIDENT OR COMPLAINT:

8. LOCATION OF THE INCIDENT OR COMPLAINT:

9. WHO ELSE MAY HAVE WITNESSED THE INCIDENT OR MAY HAVE SEEN THE

INCIDENT?

Name:

May we contact them?

Yes

10. NATURE OF THE COMPLAINT

(Be specific – who, what, when, where, how. Attach additional sheets if

necessary)

11. REMEDY REQUESTED:

In order for a complaint to be received by the Town, the complainant must sign this form

and submit to the Office of the Town Clerk.

SIGNATURE:

DATE:

For Internal Use Only: To be completed by the Town of Florence – Complaint Number

___________________________

Date Complaint Received:

Time Received:

Routed to Town Manager and:

Initial Contact to Citizens:

Date Response Sent/Phoned to Citizen:

Date Complaint closed:

Citizen Complaint Form - Town Of Florence