Consumer Protection Complaint Form

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Please correct the fields below:

Please correct the field(s) marked in red below:

Please complete your contact information:

*

Please complete your contact information:

Your Name:*

Date:*

Your Street Address:

City:

State:

Zip Code:

Your Phone Number:*

Your E-Mail:

Provide the date and time of the incident:

*

Provide the date and time of the incident:

Business Name:*

Address/Location:*

City:*

Date Incident Occurred:*

Time Incident Occurred:*

Have you contacted any other agency (Consumer or Legal), if yes which agency:*

If we contact the business, do you want your name kept confidential?:

Would you like to be informed of the result of the investigation/activities?:

Describe Complaint in Detail:

Briefly provide as much detail about your complaints as possible:

Upload any documentation, pictures or video that would help us understand your complaint:

Upload any documentation, pictures or video that would help us understand your complaint:

Click button for uploading file

Clear

Maximum size allowed: 5 MB

Allowed types: .gif, .jpg, .jpeg, .png, .doc, .docx, .xls, .xlsx, .rtf, .pdf, .txt

Upload any documentation, pictures or video that would help us understand your complaint:

Click button for uploading file

Clear

Maximum size allowed: 5 MB

Allowed types: .gif, .jpg, .jpeg, .png, .doc, .docx, .xls, .xlsx, .rtf, .pdf, .txt

Upload any documentation, pictures or video that would help us understand your complaint:

Click button for uploading file

Clear

Maximum size allowed: 5 MB

Allowed types: .gif, .jpg, .jpeg, .png, .doc, .docx, .xls, .xlsx, .rtf, .pdf, .txt

To receive a copy of your submission, please fill out your email address below and submit.
Email Address

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