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2. Full Name

   Please provide your name so we can contact you. This information will not be used for any other purposes or shared with anyone other than City staff.

3. Preferred Method for City to Contact You
   -- Select One --PhoneEmail

   This is in case we need to follow up with you on the complaint for additional information or confirmation of treatment.

5. You Phone Number

   Please provide your phone number so we can contact you. This information will not be used for any other purposes or shared with anyone other than City staff.

7. Your Email Address

   Please provide your email address so we can contact you. This information will not be used for any other purposes or shared with anyone other than City staff.

9. Full Address Including Unit #*
   The address, including unit #, must be provided so that we can ensure treatment occurs in the correct unit. You do not need to enter the City or State
11. A staff member from the Multi-Family Inspection Program will contact your landlord to ensure treatment takes place. After proof of treatment is provided from the landlord to the City, we will contact you to confirm treatment was successful.
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13. 1. Receive an email copy of this form.
14. Email address

    This field is not part of the form submission.

15. Submit

* indicates a required field