Mid-Michigan District Health Department
Complaint Form
City of Greenville Tobacco Free Outdoor Recreation Areas
1. Location of the violation (e.g. Park, Playground or Trail): *
2. Date of the violation: *
3. Time of the violation (e.g. 1:35pm): *
4. I wish to make a complaint against:
Name (if known):
Address (if known):
Phone (if known):
5. Specifics of the complaint are: *
6. How often do you use the outdoor recreation areas in Greenville: (e.g. once a week)
Your Name: *
Your Address: *
Your Phone: *
Your Email:
Please note that all complaints are confidential and that personal information is not released except in response to a Court Order
©2011 Mid-Michigan District Health Department