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COMPLAINT REGISTRATION FORM

Person filing the concern

Mr.

Mrs.

Ms.

Miss

Other

Last Name

First Name

Property Address

Phone Number (daytime)

Phone Number (evening)

Email Address:

Details of concern regarding the subject property

Address/Location of the complaint

Owner(s) of subject property

Details of concern:

In some cases, a complainant may be requested to sign an affidavit and/or be prepared to stand as a witness should enforcement action proceed to court.

Personal information contained on this form is collected for the purposes of administering the Township of Havelock-Belmont-Methuen By-laws and is done so in accordance with the Municipal Freedom of Information and Protection of Privacy Act.

Signature

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