Print out this form and mail it to:
Clark Regional Emergency Services Agency
710 West 13th Street
Vancouver, WA 98660-2810
(360) 737-1911
COMPLAINT COMMENDATION
Date Reported: __________ Time Reported: __________
Reported By: ___________________________________
Address: _______________________________________
City:____________________ State: ____ Zip: _________
Your Telephone Number with Area Code: _____________
Date Occurred: ____________ Approximate Time Occurred: _____________
Location of Occurrence:
_________________________________________________________________
What Occurred:_____________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Do you want further contact?
No.
Yes.
Telephone.
Letter.
E-mail.
E-mail address:_________________________
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For Agency Use
0 Complaint transferred to electronic format and forwarded to the Assistant
Director.
0 Commendation forwarded to the respective Division Manager.
Date:_________ Time: _______ By:_______________________