Quality of Life Action Survey

 
    Instructions:

    Please fill out the issue(s) you may have.Please provide as exact and concise information as possible. Please remember to fill-out all of the information above so we can stay in touch with you.

    Please specify

    Please specify location/description of conditions.

    Please specify location and existing conditions.

    Please specify location/description.

    Please specify location.

    Please specify location (s)

    Please specify location.

    Please specify location (street and between cross street and cross street)

    Please specify location

    Please specify location.

    Please specify description/Location/Day(s) & Time (we will forward this information to the local police precinct)

    Please provide a description of the issue you are facing and what we can do to assist you.

    In the past, I have been able to introduce legislation based on the suggestions you have provided me. Please include a detailed description of a particular issue and how you believe we can assist you at the State level: