Customer Rights And Complaint Resolution Procedure And Customer Complaint Form Page 3
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Customer Rights and Complaint Resolution Procedure and Customer Complaint Form
Complainant (person filing the complaint)
______________________________
_________________________
*NAME (PERSON AND/OR BUSINESS
E-MAIL ADDRESS
______________________________
________________________
*MAILING ADDRESS
HOME PHONE #
______________________________
_______
_________________________
*CITY/STATE
*ZIP CODE
WORK PHONE #
_________________________
CELL PHONE #
Complaint Filed Against:
______________________________
_________________________
*NAME (PERSON AND/OR BUSINESS)
E-MAIL ADDRESS
______________________________
_________________________
*MAILING ADDRESS
HOME PHONE #
______________________________
________
_________________________
*CITY/STATE
*ZIP CODE
WORK PHONE #
_________________________
CELL PHONE #
*Required Information
Provide a clear and brief statement of the facts, including relevant dates and any known violation of law, regulations, or
rules related to any federal- or state-funded workforce service. If additional space is needed, you may use the reverse side of
this form or attach a separate statement of no more than 5 pages.
The above information is true and correct to the best of my knowledge.
_______________________________________
_____________________________
Signature of Complainant
Date
FOR OFFICIAL USE
Individual Receiving Complaint:___________________________________ Title:___________________________________
City:__________________________________________________________ Telephone:______________________________
Date complaint was received:
Action Taken:
This complaint process does not pertain to matters alleging violations of nondiscrimination or equal opportunity requirements
under WIA, or matters governing job service-related complaints.
SUBMIT DOCUMENT
WDA Form # 0209
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