Please provide your contact information:

Enter the Date of the Incident:

(mm/dd/yyyy)

Enter the Time of the Incident:

(ex: 2:15 am)

When did you call for the limousine service?

Date: (mm/dd/yyyy)

Time: (ex: 2:15 am

Did you contact the limousine service or a dispatch service? (Choose one)

Limousine Company
Dispatch Service

What is the limousine company name?

What was the driver's name?

What was the pick up address:

Are you disabled?

Yes
No

If yes, what type of disability do you have?

Briefly Describe the Incident:

Did you get a service receipt?

Yes
No

Would you be willing to testify at an informal hearing by telephone regarding this incident?

Yes
No

A Consumer Affairs enforcement inspector will contact you to resolve this complaint. Thank you.