STATE OF IDAHO
BUREAU OF OCCUPATIONAL LICENSES
Owyhee Plaza
1109 Main St., Suite 220
Boise, ID 83702-5642

 ***COMPLAINT FORM***
(Please print out the completed form, sign and mail to address at the top of the form)
________________________________________________________________________________

COMPLAINT MADE BY:

                              Name:

                         Address:

                                  City: State:   Zip:

                 Home Phone:   Work Phone:

COMPLAINT IS AGAINST:

                              Name:

           Business Name:

                         Address:

                                  City: State:   Zip:

                Home Phone:   Work Phone:

                    Profession:

Details (please include below, or on a separate sheet of paper if necessary, a written account of your complaint including dates, times, names of witnesses, addresses, phone numbers, and any other relevant information. The box below will hold a maximum of 40 lines of text.)  

This complaint is true, accurate, and complete to the best of my knowledge.  (A SIGNATURE IS REQUIRED.)

Signature ________________________________________________    Date _____________

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Last Modified - Monday, February 27, 2006