Licensed Establishment Complaint Form

If you would like to file a complaint, request, or report, doing so will create a public record that is subject to disclosure pursuant to Wisconsin public records law.

Langlade County Health Department
Chapter 11 - Lodging, Recreation & Food Protection

Your Name

First Name

Last Name

Your Email

Your Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Your Phone Number

(###)

###

####

Complaint Description

Establishment Name

Establishment Phone

(###)

###

####

Establishment Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Establishment Email

Licensee Holder Name and Licensee ID Number

(if known)

Signature of Complaint

(digital signature)

First Name

Last Name

Date

YYYY

Time

Hour

Minute

Second