Customer Complaint Form

Your Information
Full Name

First NameLast Name
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Method of Contact
Alternate 'Preferred Method of Contact' Requested (if applicable)
Representative (if applicable)- COMPLETE ONLY If you are represented by someone concerning this complaint, please provide their information below.
Complaint Details
Date of the incident

MonthDayYear
Date
Description of Incident - Please describe what happened, including any interactions related to your service animal (if applicable), staff names, or locations involved.
Approximate Time of Incident

Hour Minutes

AM/PM Option
Basis of Complaint (check all that apply)
If Basis of Complaint is 'Other,' please specify:
Agency or Department Involved
If Agency or Department involved is 'Other,' please specify:
Please attach any relevant files (e.g., emails, letters, photos, screenshots, PDFs, or additional pages)

You may upload up to five (5) documents or combine them into a single PDF. Maximum total size: 10 MB.
Cancelof
Have you filed this complaint with another agency or court?
If prior action taken, please provide the Agency Name, Contact Person, Date Filed, and Status.
Accessibility Accommodations
Do you require any accommodations during the review process (e.g., large print, Braille, interpreter, relay service)?
If accessibility accommodations required is 'Yes,' please specify:
Signature and Certification
By typing my name below, I certify that the information provided is true and correct to the best of my knowledge. I understand this complaint and any supporting documentation may be shared with the entity alleged to have violated federal civil-rights requirements.
Typed Signature serves as electronic signature.
Electronic Signature Authorization
Today's Date

MonthDayYear
Date
By submitting this form, I certify that the information provided is true and correct to the best of my knowledge. I understand that the Port will review and process my complaint in accordance with its ADA & Accessibility Policy, Service Animal Accommodation Policy, Title VI Civil Rights Policy, and Privacy Policy, and that the information I provide will be used solely for the purpose of investigating and responding to this complaint.
Should be Empty:

Your Information

Complaint Details

Accessibility Accommodations

Signature and Certification