Complaint Report Form
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1Complaint Report -
Incomplete forms will not be processed. Please be sure to fill in all blanks
Date: ____________ Complaint against: __________________________________________________________
(Individual’s name AND business name)
License Number (if licensed):________________ Telephone: ( _____ ) ________________________________
Address: _____________________________________________________________________________________
Street, PO Box, Route
City
State
Zip Code
Person Filing Complaint: _______________________________________________________________________
Daytime Telephone: ( _______) _______________ Evening Telephone: (__ ____) _______________________
Address: _____________________________________________________________________________________
Street, PO Box, Route
City
State
Zip Code
E-Mail Address (for sending correspondence): _______________________________________________________
Details and Facts of Complaint
Work Performed for: _______________________________________ Contact Number: (______)______________
Address where work performed: __________________________________________________________________
Street, PO Box, Route
City
State
Zip Code
1. What was the approximate date when the work started: ______________________________________________
2. To the best of your knowledge were permits pulled for the work performed?
Yes
/
No
3. Was an inspection performed by the city or county inspection department?
Yes
/
No
4. Are you aware of any code violations or deficiencies in the work?
Yes
/
No
5. Has the contractor proposed or performed any additional work or repairs?
Yes
/
No
6. Will you allow the contractor to complete the job or make repairs?
Yes
/
No
7. Please describe the details of your complaint in the space provided below.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Please attach any additional documentation you have (i.e. Inspections reports, copy of permit, copy of contract,
photographs, etc.) to this complaint form. If you require additional space to detail your complaint please do so on
an additional separate sheet of paper and attach to this complaint form.
The above statements are true to the best of my knowledge and belief.
Complainant’s signature_________________________________________________ Date: _________________
Submit this form by any one of the three following methods:
Mail to: Complaint Coordinator, State Board of Examiners, 1109 Dresser Ct., Raleigh, NC 27609
Send via e-mail to
OR
Send via fax to (919) 875-3616
1
FOR OFFICE USE ONLY
ZONE:
FILE NUMBER:
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Parent category: Legal