Skimmer Form

Instructions

Please provide as much information as possible to explain why you believe there is a skimmer at the location you are reporting, including photos of the fuel dispensers, your receipt, facility information, and/or other evidence.

Indicate if you are a member of the public, law enforcement, merchant, or a service technician?

Public

Law Enforcement

Merchant

Service Technician

Incident Details

Date of Incident

The Date of Incident field is required.

*Required

Facility Account Number *Required

Gas Station Name *Required

Location Address *Required

Location City *Required

Location Zip Code

Name of Contact at this Location

Pump Number(s)

Number of Skimmers Found *Required

Was merchant notified?

Yes

Explain in detail why you believe a skimmer is at this location *Required

Complainant's Information

Do you want to remain anonymous?

Yes

If you check "Yes" your complaint will be submitted anonymously, If "No" is selected your contact information will no longer be considered anonymous and your information may be subject to release under the Public Information Act, Chapter 552 of the Texas Government Code.

Complainant First Name *Required

Complainant Last Name *Required

Service Technician License Number *Required

Service Company License Number *Required

Service Company Name *Required

Complainant Address *Required

Complainant City *Required

Complainant State *Required

Complainant Zip Code *Required

Complainant Email *Required

Complainant Phone *Required

Preferred Contact Method *Required

Attachments

Include pictures of skimmer(s), fuel dispensers, your receipt, facility information, and/or other evidence.