Complaint Form

Complainant

Name

Address

City/Town

State

ZIP/Postal Code

Contact #

Email

Company (if registered contractor)

Registration #

Contractor

Name

Registration #

Not Registered

Company Name

Address

City/Town

State

ZIP/Postal Code

Cell Phone

Business #

Email

Contract Information

Address

City/Town

State

ZIP/Postal Code

Type of Contract

Oral

Written

Contract Date

Total Amount of Contract

Total Paid to Date

Date Work Started

Date Work Completed

Occupancy Date

Date Work Ceased (if applicable)

Briefly Describe Your Complaint