Department of Health
John J. Dreyzehner, MD, MPH, Commissioner

Non-Smoking Complaint Form


Complainant Information

Must be able to verify the name and telephone number before a complaint can be processed.
First Name:
Middle Initial
Last Name:
Confidential:
Street Number:
Street Address:
City:
State:
Zip Code:

Daytime Phone:

Venue/Individual Information

Name:
Street Number:
Street Address:
City:
County:
Zip Code:

Phone:

If this is your place of employment, check here.

Type of Establishment:

Comment: