Citizen'S Complaint Form - City Of Floresville

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CITIZEN’S COMPLAINT FORM
DATE: ______________
TIME: ____________
Complainant:
Name: __________________________________________________________
Address: _________________________________________________________
Contact # ________________________________________________________
Nature of Complaint :
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________
Location of Complaint:
__________________________________________________________________________________
__________________________________________________________________________________
____________________________
__________________________________________________________________________________
______________________________________________
RECEIVED BY: _________________ DATE: _______________ TIME:______________
DEPARTMENT ISSUED TO:
(
) CODE COMPLIANCE
(
) WASTE/WATER SEWER
(
) PARKS
(
) MISC
(
) WATER
(
) STREETS
(
) ADMINISTRATION
(
) POLICE DEPARTMENT
***CITY MANAGER TO RECEIVE A COPY OF ALL COMPLAINTS***
Non-Discrimination Statement:
The following information is requested by the Federal Government in order to monitor
compliance with Federal laws prohibiting discrimination against applicants seeking to
participate in this program. You are not required to furnish this information, but are
encouraged to do so. This information will not be used in evaluating your application or
to discriminate against you in any way. However, if you choose not to furnish it, we are
required to note the race/national origin of individual applicants on the basis of visual
observation or surname.
Check Appropriate Ethnicity and Race:
1. ETHNICITY: _____Hispanic or Latino descent _____Not of Hispanic or
Latino descent
2. RACE: ______White ______Asian ________Black or African American
________American Indian/Alaska Native _______Native Hawaiian or Other
Pacific Islander
THE CITY OF FLORESVILLE IS AN EQUAL OPPORTUNITY PROVIDER AND EMPLOYER
FORM NO. 5-COFCUSTOMERCOMPLAINT FORM

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