Taxicab and Vehicles For Hire

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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