Pesticide Use Complaint Form

You do not have to provide the personal information requested. However, if you choose not to provide the necessary information, we may not be able to investigate your complaint.

Name

Address

City

State

Zip

Phone number

Date of incident * (required)Date of incident * (required)

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Time of incident * (required)

Physical location * (required)

Describe what happened * (required)

Contact preference

How would you like to be contacted for further questions or findings?

Phone

Attach photo/video

Links to videos

Type the characters you see in the image below * (Required)

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