You are here: Home » Refusal of Service FormRefusal of Service Form Refusal of Service Form If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required Email Phone * Your name (Road name is fine) * City where incident occurred * Date of Incident * Location of incident * Refusal of Service: Name and location of business Refusal of Service: Names, titles, etc. of individual(s) Refusal of Service: What happened? Refusal of Service: Any other info you feel is important What is 3 + 8 *