1 Your Contact Information2 Type of Problem3 Details: Time & Location4 Details: Write it Out5 Sign & Submit Please report your non-emergency issue to the Town of South Coffeyville via the 5-step form below. You may also call city hall during normal business hours, weekdays 8:00 am -5:00 pm. If this is an emergency please contact 911. All received forms will be handled by the respective departments or representatives that the problem pertains to. Your Contact InformationThis will be the information that the Town of South Coffeyville will use to contact you regarding your reported problem.Name* First Last Your Phone Number*Email* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Type of ProblemPlease choose the category or city department that your problem most closely relates to. Only choose one category/department.Type of Problem*UtilitiesTrash ServicesStreets (Lights, Street Signage, Sidewalks, etc.)Parks & Recreation (Includes Swimming Pool)Business Code Violation (i.e. Signage Violation)Issue with City Employee or ContractorCity Code Violation (i.e. Zoning violation or animal violation)OtherDescribe Your "Other" Type of Problem* Details of Your Problem (Time & Location)In this section you will elaborate on the vital information needed to help the Town of South Coffeyville address your problem.Date Problem Occurred* Approximate Time Problem Occurred* : HH MM AM PM Where did the Problem Occur?*Your HomeLocal BusinessCity ParkCity BuildingCity Street or IntersectionOtherName of City Building Where Problem Occurred* Name of City Building Name of City Street or Intersection Where Problem Occurred* Name of City Street or Intersection Name of City Park or Rec Facility Where Problem Occurred* Name of City Park Name of Local Business Where Problem Occurred* Name of Local Business Explain the "Other" Place Where Problem Occurred* Details of Your ProblemIn this section you will elaborate on the vital information needed to help the Town of South Coffeyville address your problem.Name of City Employee or Contract for Whom Issue Occurred With* First Last Please Explain Your Problem Thoroughly*Avoid using any unnecessary harmful or discriminatory language regarding individuals or local businesses.Your Desired Solution to the Problem*There is no guarantee that this solution will be implemented, but this will help the city in the conflict resolution phase with you and other parties involved in the conflict.Upload Supporting PhotosUpload any photos that accompany your issue and will help with the resolution of the problem. Drop files here or Upload Supporting DocumentsUpload any documents that accompany your issue and will help with the resolution of the problem. Drop files here or Sign Form for SubmissionBy signing this form you're hereby verifying that all information provided to the Town of South Coffeyville Oklahoma within this form is accurate to the best of your knowledge. Any content provided within this form (i.e. documents, photos, statements, etc.) are hereby released to the Town of South Coffeyville Oklahoma for the use of resolving this problem.Enter Your Name* First Last Best Way to Reach You*Phone - DaytimePhone - EveningEmailYears Lived in the Town of South Coffeyville*I hereby verify that everything I provided within this form is accurate to the best of my knowledge.* I Agree PhoneThis field is for validation purposes and should be left unchanged.