Complaint Form - Transportation

Please fill out the information requested in this complaint form. Once completed, we will mail or e-mail your complaint number to you, along with the information you entered. Please write down your complaint number and keep it in a safe place. You will need it to inquire about the status of your complaint.


Note: * Indicates a required field.

*First Name:   Initial:     *Last Name:  
*Address:
Address 2:
*City:   *State:       *Zip:  
*Phone:
*E-mail:
If you are a representative for complainant, please fill out this section:
Name:
Phone:
Reason why complainant cannot complete this form:
 
Driver Name:
Driver Badge Number:
Taxi Permit Number:
(from side of cab)
License Tag number:
(if not a taxicab)
Company Name
Date of Incident:
Time of Incident:
Location of Incident:
*Describe your complaint in detail: