Complaint Form for Spraying of Anvil 2+2 in Nashville, TN

Fill this form out if:
1. You were sprayed when you opted out.
2. You've seen people sprayed who were out when trucks came or you have been sprayed by the truck drivers. (If you had any adverse effects, fill out an incident form.)
3. Trucks sprayed your neighborhood without sounding horns before 8:30 PM.
4. Trucks came earlier than scheduled.
5. Any other complaint. Unless you've have had adverse effects from Anvil 2+2 (sickness, sore throat, asthma attack, etc), had fish die or have found any other dead or sickened wildlife after spraying then fill out an INCIDENT REPORT (see link on HOME page.)

Today's date____________________ When event happened_____________________

Name_______________________________________ Zone, if known (circle one): 1 2 3 4

Address____________________________________ City______________________ Zip___________

Phone_______________________________ E-mail ____________________________________

Explain what happened. Please include a detailed description. (Examples: people you spoke with, location, etc.) You may attach additional: statements, documents, photos, etc. to this form.

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

(Disclosure Approval) I, _________________________________________, hereby give my permission to release this form and/or the information contained herein to the media, policy makers, and organizations working to improve mosquito control methods and notificatin policies.

______________________________________________________

Signature.............. Date

Return to: BURNT/No Spray Nashville, 217 Silo Court, Nashville, TN 37221

Phone: (615) 327-8515, E-mail: nospraynashville@earthlink.net, Fax: (615) 662-0512