2. Date and Time of Service*
   Date and Time of Service

   Date and Time of Service
3. Receipt Number*
5. Name*
6. Email Address*
8. Service Address*
10. City
11. State
12. Zip Code
14. Were you greeted when you entered the office?*

    1. Yes
    2. No
16. How many clerks did you see at the front counter?*

    1. One
    2. Two

    1. Three
    2. Four
18. What was your reason for visiting our office today?*

    1. Paying a bill
    2. Billing Inquiry
    3. New Service
    4. Complaint
    5. Other
19. What was your Complaint?*
20. Did the clerk answer/respond to your complaint?*

    1. Yes. I am satisfied
    2. Yes, but I am still not satisfied.
    3. No.
22. If you were unsatisfied with the information the clerk provided, did you speak with the Customer Service Supervisor?*

    1. Yes.
    2. No.
23. Was the Customer Service Supervisor able to help you or at least present you with information concerning your complaint?*

    1. Yes
    2. No
25. Please Explain*
26. If you are unhappy with the solution that you were given, how would you have liked the situation to have been resolved?*
28. Do you feel that you were treated in a courteous and professional manner?*

    1. Yes
    2. No
29. Anything outstanding that we may share with the clerk?
30. Anything that you would like management to address?
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32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit Submit and Print

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