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2. Please use this form to report any issue with HAWC
4. First Name
5. Last Name
7. Phone Number

   If you would like a response, please leave your phone number or email address

8. Email Address
10. What type of issue are you reporting?

    1. I received poor service quality
    2. I was unable to call/access HAWC
    3. I was denied a service I believe I am eligible for
    4. Other (please describe below)
12. What was the date and time of your interaction with HAWC?
    What was the date and time of your interaction with HAWC?

    What was the date and time of your interaction with HAWC?
14. Who did you speak with at HAWC?
16. Please describe the issue you would like to report.

    Every detail you provide will help us respond effectively. Please also include any steps you have already tried to resolve the situation.

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18. 1. Receive an email copy of this form.
19. Email address

    This field is not part of the form submission.

20. Submit

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