Licensed Establishment Complaint Form

Licensed Establishment Complaint Form

The Fergus County Health Department reviews and responds to all complaints received from the community. Please file your complaint using this online form. All complaints must be in writing. We do respect your privacy and will keep your contact information confidential. Although complaints may be filed anonymously, investigators are able to more thoroughly investigate the complaint if able to communicate with you on details regarding the situation. Please complete information to the best of your ability.
Date

MonthDayYear
Date
Business Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Nature of Complaint: Please be as specific as possible and provide any evidence (photographs, etc) in order for us to proceed with the investigation.
Contact Information: Please understand that if you would like to submit an anonymous complaint, no further contact will be made with you in regard to this matter.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Should be Empty: