Complaint Form Municipal Investigation

IN ACCORDANCE WITH SECTION 239 of the MUNICIPAL ACT 2001 (as Amended)

PLEASE PRINT AND FORWARD COMPLETED FORMS TO:

Amberley Gavel Ltd.
35 Amberside Drive
London, ON N6G 4M3

Complainant's Name

Address

City/Province

Postal Code

Telephone Home

Telephone Work

Email Address

Can your identity be revealed during the investigation?

Yes

* PERSONAL INFORMATION IS COLLECTED UNDER THE AUTHORITY OF SECTION 239 OF THE MUNICIPAL ACT 2001 (as AMENDED) AND WILL BE USED BY THE MUNICIPAL INVESTIGATOR TO CARRY OUT AN INVESTIGATION UNDER THE ACT.

Name of Municipality

Date of Closed Meeting

Municipal Contact Name

Telephone

BACKGROUND - This should provide as much information as required to explain the nature and background of the particular occurrence (ie. Timing; Municipal Contact; Municipal Explanation).

ACTION - Activities that the complainant has undertaken to resolve the matter.

SUMMARY/COMMENTS:

Date of Signature

Signature of Complainant

Clear

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