Complaint Form

All of the information with * next to them are required.

Name:

Address:

City:

State:

Zip:

Phone:

Email:

Classification:

License Number:

If the Complaint is on a Facility or an Individual that doesn't have a license you must use this form to file a complaint.

Complaint Details:

*Click here to verify a license number.

I certify that I am the person shown above, and all the information is correct.