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Complaint Form

Person Making the Complaint
NOTE: You may submit a complaint anonymously.  However, if you would like to receive a response
regarding your complaint, you must at least specify an e-mail address or phone number.
Your Name:
  First Middle Last
Your Address: /
  Street City State / Zip Code
Home Phone: ex: 000-000-0000
Work Phone: ex: 000-000-0000
E-Mail Address: ex: jdoe@email.com
Person or Firm You Are Complaining About
  First Middle Last
Address: /
  Street City State / Zip Code
Phone: ex: 000-000-0000
Incident Details
Where did the offensive conduct take place?
On what date did the conduct occur? ex: mm/dd/yyyy
At what time?
Who witnessed or has knowledge of the conduct you are complaining about? Please list names and phone numbers with a description of what was observed.
Please explain your relationship to the person you are complaining about.
Have you spoken to the person you are complaining about? Yes No
If yes, nature of response:
Have you filed a suit with the courts on this matter? Yes No
If yes, date filed: ex: mm/dd/yyyy
Case number:
RequiredPlease specify your complaint, listing the details of the event as they occurred:
(To print a copy of this complaint for your files, Select FILE and then PRINT in your browser before clicking Submit Complaint.)


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