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2. Today's Date*
   Today's Date
4. Complainants Name*
5. Complainants Address*
7. Complainants Contact Number*
8. Complainants Email Address*
10. Name of Complainee (if known)
11. Address of Complainee*
13. Date of Alleged Violation(s)*
15. Nature of Violation(s)*
17. Attachments
21. Within 14 days of your receipt of this request, I anticipate a response stating any action or refusal to act upon this complaint and reasoning therefore. I believe the above facts are true & understand that it is necessary for the Town of Blackstone to institute legal action in courts. Therefore, I agree to testify as a witness on behalf of the Town of Blackstone should my concerns escalate. I also understand that any concerns I submit anonymously may not be looked into, nor will I receive the results of any outcome.*

    By checking the "I agree" box below, you agree and acknowledge that 1) your form will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
23. Electronic Signature
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25. 1. Receive an email copy of this form.
26. Email address

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27. Submit

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