Utkarsha-Nimapada

YOUR DETAILS

Full Name* :

Mobile Number* :

Address* :

Ward / Panchayat / Village / Town* :

TYPE OF GRIEVANCE (Select one or more)

Road

Drainage Problems

Drinking Water

Electricity Issues

Health Services

Hospital Complaints

School

Education Related

Youth

Employment Problems

Not Receiving Government Scheme Benefits

Others

Others* :

DESCRIPTION OF YOUR GRIEVANCE

Please describe your issue clearly. Include location, who is affected, and since when it is happening* :

WHAT HELP OR ACTION DO YOU EXPECT?

Please Describe Your* :

DO YOU WANT TO BE CONTACTED FOR FOLLOW-UP?

Yes – Please call me

Yes – Please send SMS/What’s App

No – Just record my grievance

UPLOAD SUPPORTING DOCUMENT OR PHOTO (Optional)

Upload* :

Date of Submission * :

Captch* :

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Grievance