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2. Items with an asterisk (*) are required.
4. First Name
5. Last Name
7. Phone Number
9. Would you like a follow-up on your complaint?

   1. Yes
   2. No
11. Establishment Name
13. Address of Complaint*
15. Can it be seen from the street?*

    1. Yes
    2. No
17. Please provide specific details regarding your complaint:*
19. Attach any relevant media regarding your complaint
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21. 1. Receive an email copy of this form.
22. Email address

    This field is not part of the form submission.

23. Submit

* indicates a required field