COMPLAINT FORM

TO BE COMPLETED BY THE COMPLAINANT:

COMPLAINANT INFORMATION

RESPONDENT INFORMATION

11. STATEMENT Explain as clearly as possible. Attach any pertinent documentation at the end of this form.
12. Electronic Signature:

I CERTIFY the information furnished is true and accurate to the best of my knowledge. I AUTHORIZE the disclosure of this information as needed for the proper investigation and enforcement of my complaint. I UNDERSTAND my identity will be kept confidential to the maximum extent possible, consistent with applicable law and a fair determination of my complaint. I also understand it is against the law for my employer to discharge, intimidate, retaliate, coerce or discriminate against me for filing this complaint.
 
11/14/2019
14. The customer submitting this complaint either requested assistance or submitted the complaint form by email or on paper. I have completed this form based on the information provided by the customer to the best of my ability.

You may attach up to five supporting documents. NOTE: Each file must be less than 1.5 MB in size. Only the following file types are allowed: pdf, bmp, gif, jpg, jpeg, png

 

 

 

 

 
Idaho