In order for the Texas Department of Agriculture to pursue an investigation of a complaint please provide all information related to your complaint, including a complete explanation of your complaint.

Incident Details:
Date of incident: 
* Feedback or information to offer: 
* Grade of fuel: 
* Pump Number 
Incident business name: 
Incident business license ID: 
Name of contact at location: 
* Street: 
* City: 
County: 
State: 
Zip: 

Your Details:
Do you wish to  
remain anonymous?  
Preferred  
contact method:  
Prefix 
* First Name 
MI 
* Last Name 
* Address Line 1 
Address Line 2 
* City 
* State 
* Zip 
* Email 
Phone