Complaint Form - State Of New Mexico Board Of Licensure For Professional Engineers And Professional Surveyors

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S t a t e o f N e w M e x i c o
Board of Licensure for
Professional Engineers and Professional Surveyors
Office of Compliance and Enforcement
M a i l i n g : P.O. Box 25101 Santa Fe, New Mexico 8750 4 • L o c a t i o n : Toney Anaya Building • 2550 Cerrillos Rd.
(505) 476-4565 • www. sblpes.state.nm.us
C O M P L A I N T F O R M
I . C o m pl a i na nt
(Person making the complaint)
NAME - LAST
FIRST
INITIAL
MAILING ADDRESS – NUMBER AND STREET / POST OFFICE BOX
CITY
STATE
ZIP CODE
BUSINESS OR MESSAGE TELEPHONE
HOME TELEPHONE
EMAIL ADDRESS
I I . R e s p o nde nt
(Person being complained about)
NAME - LAST
FIRST
INITIAL
COMPANY / FIRM NAME
MAILING ADDRESS – NUMBER AND STREET / POST OFFICE BOX
CITY
STATE
ZIP CODE
BUSINESS / HOME TELEPHONE
BUSINESS / HOME FACSIMILE
EMAIL ADDRESS
I I I . W i t ne s s e s
(If any, have each witness complete an Affidavit of Witness Form)
NAME
ADDRESS
TELEPHONE
F O R O F F I C I A L U S E O N L Y
–
D O N O T W R I T E B E L O W T H I S L I N E
–
Case Number: ____________________
Case Class:
PE
PS
Unlicensed Engineer
Unlicensed Surveyor
Investigator Assigned: ________________________________________
Technical Investigator Necessary ?
No
Yes
Technical Investigator Assigned: ________________________________
R E C E I V E D D A T E
rev 7/15
Form CP-002

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