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2. City of Purcell Complaint Form

   230 W. Main Street
   Purcell, OK  73080
   (405) 527-6561

4. Full Name*
5. Email Address*
7. Address*
9. City*
10. State*
11. Zip Code*
13. Phone Number*
14. Date and Time
    Date and Time

    Date and Time
16. Address of Complaint*
18. Check all that apply:*

    1. Electrical Problem
    2. Animal Nuisance
    3. Street Problem

    1. General Complaint
    2. Water / Wastewater Problem
    3. Code Violation Nuisance

    1. Street / Security Light Outage
    2. Park Issue
    3. Trash Service
20. Please describe the issue you are experiencing below:*
22. For City Use Only

    Date Received: _____/_____/__________

    Received by:  _____________________________

    Forwarded To:  ____________________________
                                          Name / Department

24. The City of Purcell is an Equal Opportunity Provider and Employer.  In accordance with Federal law and the U. S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color national origin, sex, age or disability.  (Not all prohibited bases apply to all programs.)  To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W. Washington, D.C.  20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TDD 711)

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26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit

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