ULHASNAGAR MUNICIPAL CORPORATION CITIZEN FACILITATION CENTRE SUBJECT:- COMPLAINTS REGARDING PUBLIC WORKS 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) [ ] Filling of pothole [ ] Filling of digged roads. [ ] Removal of shrubs and bushes on the road. [ ] Digging of roads without permission. [ ] Necessary/unnecessary Speed breakers. [ ] Unclear lane painting on roads . [ ] Repairing of dividers on road. [ ] Installing name plates on the road [ ] Name plates on road not in good condition. [ ] Zebra crossings not provided on roads [ ] Height of Speed breakers [ ] Repairing of gutters. [ ] Closing of the gutters / chambers with lids / net [ ] Dangerous buildings / structures. [ ] Others Details of Complaint:- [Note:- Please attach necessary documents regarding Complaint.] Applicant's Signature
