Licensed Contractor Complaint Form - Nevada State Contractors Board Page 2
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4NEVADA STATE CONTRACTORS BOARD
FOR OFFICE USE ONLY
License No:
RENO OFFICE
HENDERSON OFFICE
9670 Gateway Dr, Ste 100
Date Received:
2310 Corporate Cir. #200
Reno, NV 89521
Henderson, NV 89074
(775) 688-1141
(702) 486-1100
Contractor:
Fax (775) 688-1271
Fax (702) 486-1190
Case File No:
CONSUMER COMPLAINT FORM
I wish to initiate an investigation against the contractor named below. If the contractor is licensed, he/she will be
notified to expedite the resolution of this matter. All requests for investigations concerning workmanship and
money owing issues must be in writing.
TO HELP RESOLVE THIS COMPLAINT, PLEASE ANSWER AS MANY OF THE FOLLOWING QUESTIONS AS POSSIBLE
1. PERSON MAKING COMPLAINT
2. CONTRACTOR INFORMATION (COMPLAINT AGAINST)
YOUR NAME:
(Last,First,Middle)
CONTRACTOR NAME
(as shown on contract/invoice)
YOUR COMPANY NAME: (If Licensed Contractor or Supplier)
License No.:
ADDRESS:
ADDRESS:
(City)
(State)
(Zip Code)
(City)
(State)
(Zip Code)
PHONE WHERE YOU CAN BE REACHED: (8:00 a.m. -5:00 p.m.)
PHONE NUMBER: (include area code)
HOME PHONE include area code
Email
PERSON DEALT WITH:
COMPLAINT ORIGIN
Complaint by Owner Complaint by General Contractor Against Subcontractor
Complaint by Subcontractor Against General Contractor Complaint by Material or Equipment Supplier Other
PROJECT INFORMATION
3. OWNER OF CONSTRUCTION SITE: (Name)
4. CONSTRUCTION SITE NAME: (If applicable)
ADDRESS:
(Number & Street)
ADDRESS:
(Number & Street)
(City)
(State)
(Zip Code)
(City)
(State)
(Zip Code)
PHONE NUMBER: (include area code)
PHONE NUMBER: (include area code)
5. DESCRIBE BRIEFLY THE WORK FOR WHICH YOU CONTRACTED:
6.CONTRACT DATE:
7. AMOUNT
8.AMOUNT PAID ON CONTRACT:
9. DATE WORK STARTED:
10. DATE WORK CEASED:
11. WHY DID YOU CHOOSE THIS CONTRACTOR?
REGULAR CUSTOM
ER
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OTHER: EXPLAIN
・
・
・
DOOR
-TO-DOOR SOLICITATION
REFERRED BY SOMEONE
(ENCLOSE COPY OF AD IF POSSIBLE)
・
・
Revised 3/2012
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