Form

Required fields are marked with asterisks (*)

City Facility Concern Form

Your personal information is being collected under the authority of section 25 of the Local Authority Freedom of Information and Protection of Privacy Act. This information will only be used to administer the program/activity it was collected for. If you have any questions about the collection please contact the Office of the City Clerk at 780-875-6184 or email cityclerk@lloydminster.ca

First Name:

Last Name:

Which facility did you attend?

Please check the box(s) that apply to the situation:

Customer Service Concern

Near Miss

Hazardous Condition

Observation

Safety Concern

Incident or Accident

Please provide a detailed description of the situation:

Would you like to request a follow up?

Yes

Email Address:

Phone Number: