Complainant Information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Institution Information
Name of Institution
Are (or were) you a student of the school?
Yes
No
Start Date of Program
-
Month
-
Day
Year
Date
Last Date of Attendance
-
Month
-
Day
Year
Date
Level of Degree
Certificate
Undergraduate
Graduate
Indicate your relationship with the school (i.e. parent of student, school official)
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Details of Complaint
What is the nature of the complaint?
Consumer Protection
Licensing/State Authorization
Quality of Education
Civil Rights
Other
What are the events that led to this complaint? Specify pertinent dates, the nature of the event (i.e. meeting, written appeal, judicial hearing), and school staff involved.
How have you attempted to resolve the complaint with the school?
How would you like to see the complaint resolved?
Have you filed this complaint with another organization?
Yes
No
List the organization's name(s) and the outcome of the complaint.
Have you contacted a private attorney?
Yes
No
Have you started a court action?
Yes
No
Please provide specifics below.
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Certification
I hereby certify that I am the named complainant and that the above statements are true. I understand that this complaint and the information provided may be shared with the school or other appropriate agency.
Name of Complainant
First Name
Last Name
Signature
Date
-
Month
-
Day
Year
Date
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