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2. Note
   Customer Service is a priority of the City of Portage. Your comments are appreciated. Remember to include your contact information to allow for a follow-up communication.
4. Name
5. Email Address
7. Address
9. City
10. State
11. Zip Code
13. Home Phone Number
14. Cell or Work Number
    Include an extension, if applicable.
16. Age
18. Type of Comment

    1. I Want to Commend...
    2. I Want to Suggest That...
    3. I Want to Complain About...
19. Badge Number(s) or Officer Name(s)
21. Date and Time of Incident or Occurence
    Date and Time of Incident or Occurence

    Date and Time of Incident or Occurence
23. Incident Address
25. City
26. State
27. Zip Code
29. What did he / she / they do?
Leave This Blank:


31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit

* indicates a required field