2. Taxicab and Vehicles For Hire
4. First Name
5. Last Name
7. Address
9. City
10. State
11. Zip Code
13. Phone Number
14. Fax Number
16. Date & Time of Incident*
    Date & Time of Incident

    Date & Time of Incident
17. Location of Incident
19. Email Address
21. Feedback Type

    1. Compliment
    2. Lost Item(Not Uber & Lyft, Go To TNC Link)
    3. Overcharge
    4. Refuse Fare
    5. Refused to Turn on Meter
    6. Not Accepting Credit Cards
    7. Credit Card Equipment Not Functioning Properly
    8. Driver Conduct
    9. Unprofessional
    10. Refused to Transport Me With My Service Animal
    11. Service
    12. Other
23. Additional Information About the Incident
25. Taxi CPNC #(if Known)
27. Taxi Cab Company (if know)
29. Driver's Permit Number(if Known)
31. Driver Name(if Known)
33. Vehicle Make/Model/Type (if Known)
35. Would you be willing to come to an administrative hearing if we issue the driver a summons?

    1. Yes
    2. No
37. Did you receive a receipt?

    1. Yes
    2. No
39. Do you have a picture of a license/receipt/etc. that you can upload here?

    1. Yes
    2. No
41. If yes, please click here to upload your file.
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43. 1. Receive an email copy of this form.
44. Email address

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45. Submit

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