Form Builder

Required fields are marked with asterisks (*)

Accessibility Feedback Form

Thank you for visiting the United Counties of Leeds and Grenville. We value all of our customers and strive to meet everyone's needs.

Please tell us the date and time of your visit:

Date:

Time:

Staff member, department of service location you visited:

Did we respond to your customer service needs today?

Yes

Was our customer service provided to you in an accessible manner?

Yes

No (please explain below)

Somewhat

Did you have any problems accessing our goods and services?

Yes (please explain below)

Somewhat (please explain below)

Please add any comments you may have:

Contact Information (optional):

Attention: Accessibility Coordinator
25 Central Avenue, Brockville, ON K6V 4N6
Phone: 613-342-3840 Fax: 613-342-2101

www.leedsgrenville.com

Personal information contained on this form is collected pursuant to Ontario Regulation 429/07, the Accessibility Standards for Customer Service and will be used for the purpose of responding to your request. Disclosure of this information is subject to the Municipal Freedom of Information and Protection of Privacy Act. Questions should be directed to the Clerk's Office, 25 Central Avenue West, Suite 100, Brockville, ON K6V 4N6