Citizen Service Request Feedback Form

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                        Village of




                         419 Richmond Road                             Phone: 847-251-1666
                         Kenilworth, IL 60043                          Fax: 847-251-3908
                                         E-mail: info@villageofkenilworth.org


Citizen Service Request & Feedback Form
We welcome suggestions or remarks concerning programs, facilities, personnel, services, etc.

Personal Information


Full Name: ________________________________________________________________________

Address: _________________________________________________________________________

Telephone: ______________________ E-Mail:___________________________________________

Should we contact you at this address? __________________________________________


Type of Activity (Check All that Apply)

____ Drainage/Storm Sewer         ____Park Issue                              ____Traffic Sign or Signal

____Street Problem                ____Construction Issue                      ____Street Light

____Sidewalk                       ____Zoning Issue                           ____ Water Billing Issue

____Parkway Tree Damage           ____Overgrown Grass/Weeds                   ____ General Information

____Tree Trimming                 ____Parking                                 ____ Unsafe/Hazard

____ Other (specify below)

Service Request Location: _________________________________________________________

Property Owner’s Name: _____________________________________________________________

Telephone: ______________________ E-Mail:___________________________________________

Details of Request (Be sure to indicate the date, time, etc.): _________________________________

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 Action Taken

Referred to: ______________________________________________________________

Inspected by: ______________________________________________________________________

Date Inspected: ____________________________________________________________________

Action Taken:     ( ) For Your Information           ( ) No Action - No Jurisdiction

                  ( ) Per Your Request               ( ) No Action (Reason)

                  ( ) Work Order Issued


Notes: ___________________________________________________________________________

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Was citizen notified?   YES    NO     How? ______________________ Date___________