Complaints Against Institutions: Information Sheet And Form Page 2
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1
2
3COMPLAINT FORM
I. COMPLAINANT INFORMATION
A. First Name:
M.I.
Last Name:
B. Street Address:
C. City:
State:
Zip Code:
Country:
(If outside of USA)
D. Telephone Number:
Fax Number:
E. Email Address:
F. Name of College or University Named in the Complaint
G. Status in Relation to the College or University:
STUDENT
PARENT
FACULTY
OTHER:
H. Current Student Status (If applicable):
ENROLLED
GRADUATED
PROBATION
WITHDRAWN
TERMINATED
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Parent category: Medical