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DBPR 0070-1 - Uniform Complaint Form


State of Florida
Department of Business and Professional 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.


8/22/2017

COMPLAINANT INFORMATION


Last Name:
First Name:
Middle Name:
Title:
Suffix:
Your Company/Occupation:

Mailing Address

Street Address or P.O. Box:
City:
State:
Zip Code:
County (If Florida Address):
Country:

Contact Information


Primary Phone Number:
Primary E-Mail Address:


Unlicensed Activity Complaint?
Yes   No   Unknown
  

COMPLAINT DESCRIPTION



Contact Person (If Other Than Yourself)

Last Name:
First Name:
Middle Name:
Title:
Suffix:

Mailing Address

Street Address or P.O. Box:
City:
State:
Zip Code (+4 Optional):
County (If Florida Address):
Country:

Contact Information

Primary Phone Number:
Primary Email Address:

Private Attorney for Complainant (If Applicable)

Last Name:
First Name:
Middle Name:
Title:
Suffix:

Mailing Address

Street Address or P.O. Box:
City:
State:
Zip Code (+4 Optional):
County (If Florida Address):
Country:

Contact Information

Primary Business Phone:
Primary E-Mail Address:

Subject of Complaint

Last Name:
First Name:
Middle Name:
Title:
Suffix:
Company/Organization:
License Number:

Mailing Address

Street Address or P.O. Box:
City
State:
Zip Code (+4 Optional):
County:
Country:

Contact Information

Primary Phone Number
Primary E-Mail Address:

Residence Address (If Different Than Mailing Address)

Street Address or P.O. Box:
City:
State:
Zip Code (+4 Optional):
County (If Florida Address):
Country:

Private Attorney For Subject Of Complaint (If Applicable)

Last Name:
First Name:
Middle Name:
Title:
Suffix:

Mailing Address

Street Address or P.O. Box:
City:
State:
Zip Code (+4 Optional):
County (If Florida Address):
Country:

Contact Information

Primary Phone Number:
Primary E-Mail Address:

Witness (If Applicable)

Last Name:
First Name:
Middle Name:
Title:
Suffix:

Mailing Address

Street Address or P.O. Box:
City:
State:
Zip Code (+4 Optional):
County (If Florida Address):
Country:

Contact Information

Primary Phone Number:
Primary E-Mail Address:

Witness (If Applicable)

Last Name:
First Name:
Middle Name:
Title:
Suffix:

Mailing Address

Street Address or P.O. Box:
City:
State:
Zip Code (+4 Optional):
County (If Florida Address):
Country:

Contact Information

Primary Phone Number:
Primary E-Mail Address:


I affirm that I have provided the above information completely and truthfully to the best of my knowledge. Whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his official duty shall be guilty of a misdemeanor of the second degree (Florida Statute 837.06).


Complainant Sign Here:___________________________________________

Date:_______________________________