Please provide the following contact information:

First name
Last name
Home Phone
Cell Phone
E-mail

Enter the Date of the Incident:

Enter the Time of the Incident:

Did you Hail the cab from the street?

Yes
No

Did you Call for the cab by phone?

Yes
No

What was the cab company name?

What was the cab number?

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 taximeter receipt?

Yes
No

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

Yes
No

A taxicab association representative will contact you within fourteen days to resolve this complaint. Thank you.