Refused All Services – Fair Housing Long Beach

Refused All Services *

Name of Person Refusing Services *

First

Last

Today's Date

DR OR Call#

Location of Occurrence *

Officer Name *

Officer DID# *

Does the Person Refusing Services have an address?

Address

Address Line 1

Address Line 2

City

State

Zip Code

Referred Person's DOB *

Officer Notes

Photo or CDL Image Upload

Click or drag a file to this area to upload.