ULHASNAGAR MUNICIPAL CORPORATION CITIZEN FACILITATION CENTRE SUBJECT:- COMPLAINTS REGARDING PUBLIC HEALTH Token Number (For Office Use) Date:- / / Citizen Identification Number (If Citizen Identification Number is given, do not fill below Details) Applicant's Details: Last Name/ Surname Name Father/Husband's Name Details of Society (If Application from Society): Name Of Society: Designation Address: Head Information House/Building/Soc. Name: Flat/Block/Barrack No.: Wing/Floor: Road/Street/Lane: Area/Locality/Town/City: Taluka: Pin code: Wards Committee No.: 1 [ ] 2 [ ] 3 [ ] 4 [ ] Electrol Panel No.: Telephone No. (if any): Contact Person: Email Address (if any): Classification: - (Tick [ ] whichever applicable) [ ] Waste / Garbage on roads not collected in dust bins. [ ] Cleaning of bins [ ] Placing of Dust Bins at certain places. [ ] Waste / Garbage in the city not lifted other than dust bins [ ] Dumper / Compactor not arrived for lifting the garbage [ ] Waste / Garbage in Corporation's Market is not lifted. [ ] Roads not cleaned properly [ ] Cleaning of Public Toilets [ ] Nuisance / trouble due to mosquitoes. [ ] Nuisance / trouble due to stray animals. [ ] Choke-up of gutters [ ] Bins not cleaned properly [ ] Lifting of dead animals. [ ] Cleaning of gutters [ ] Others Details of Complaint:- Applicant's Signature [Note:- Please attach necessary documents regarding Complaint.]
