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DBPR DDC1-1 Drugs, Devices, and Cosmetics Complaint Form


State of Florida
Department of Business and Professsional Regulation
2601 Blair Stone Road
Tallahassee, FL 32399-1047


If you have any questions or need assistance in completing this form, please contact
the Department of Business and Professional Regulation, Customer Contact Center, at 850-487-1395.


12/10/2019

Section 1 - Establishment Information


Name:
Address:
City:
County:
State:
Zip Code:
Business Phone (If Known)
License Number (If Known):

Section 2 - Complainant Information (Optional)


Last Name:
First Name:
Middle Name:
Title:
Suffix:
Organization Name
(If representing an organization, please provide the name of the organization):

Contact Information

Primary Business Phone Number:
Primary Home Phone Number:
Primary E-Mail Address:


Does the Complainant want to be contacted?
Yes   No

Section 3 - Details of the Complaint





I affirm that I have provided the above information completely and truthfully to the best of my knowledge.