MDA Webforms | Animal-Health-Complaint-Submittal

Please DO NOT include any personal, confidential, and/or sensitive information in your responses on this form (e.g. social security number, credit card information, health information, account number, etc.).

Complainant Information

Prefix

Last Name *

First Name *

Middle Initial

Suffix

Business Name

Address 1*

Address 2

City*

State*

County

Zip Code *

Ext. -

Primary Phone*

* x

Phone Type * Ext.

Alternate Phone 1

* x

Phone Type * Ext.

Alternate Phone 2

* x

Phone Type * Ext.

Alternate Phone 3

* x

Phone Type * Ext.

E-mail Address

Confirm E-mail Address

Subject of Complaint

Provide the full name and address of the person/business against whom you are filing this complaint.

Prefix

Last Name*

last name required Last Name	First Name *	first name required	Middle Initial		Suffix	required

Name of Business

Address 1*

Address 2

City*		State*	state required	Zip code*	zip code required zip code invalid zip code extension invalid Zip Code - Ext
County

Primary Phone

phone required phone invalid primary phone	Phone Type type required	Ext.

Phone 1

phone required phone invalid Alternate Phone 1	Phone Type type required	Ext.

Phone 2

phone required phone invalid Alternate Phone 2	Phone Type type required	Ext.

Phone 3

phone required phone invalid Alternate Phone 3	Phone Type type required	Ext.

Details of Complaint

Species

Please state your complaint briefly and clearly, noting specific violations of the law.*

details of inquiry

Witness

Provide full names and addresses of any other persons/witnesses who can verify the facts alleged.

Prefix	required
Last Name		First Name	Middle Initial	Suffix	required

Address 1
Address 2

City		State	required	Zip code	zip code required zip code invalid zip code extension invalid Zip Code - Ext
County

Primary Phone

phone required phone invalid primary witness phone	Phone Type type required	Ext.

Upload

Attach copies of documents (bills, correspondence, pictures, etc.) that would substantiate your complaint.

Upload Name
JPEG , JPG , PDF

Signature

I accept the terms and conditions

Legal Name*

Date 04/26/2024

Animal Health Complaint Submittal