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2. Name
3. Email Address
5. Address
7. City
8. State
9. Zip Code
11. Phone Number
13. *Please describe below in detail the nature of the complaint. Include dates, names, person(s) spoken to. Include any correspondence (email, letters, etc.) relating to the complaint. Attach additional sheets if necessary. Nature of Complaint:
15. Disclaimer
    The Township of Clark, the Township of Clark Health Department, its agents and/or employees cannot guarentee any expectations of privacy or anonymity. It may be necessary to subpoena the complaint(s) should legal action be necessary to achieve compliance.
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17. 1. Receive an email copy of this form.
18. Email address

    This field is not part of the form submission.

19. Submit Submit and Print

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