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| YOUR INFORMATION |
Your First and Last Name
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Address
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City
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State
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Telephone Number
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Email
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| COMPANY INFORMATION |
Name of business complaint is against
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Name of individuals to whom you complained
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Company Address
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Company City
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Company State
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Company Telephone Number
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Product or Service Purchased
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Date of Purchase
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Purchase Price
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| OTHER AGENCIES |
What action has been taken so far?
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Have you retained an attorney?
YesNo |
If Yes, Attorney Name
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Attorney Address
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Attorney City
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Attorney State
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Attorney Telephone Number
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| ADDITIONAL INFORMATION |
Have you filed a legal action?
YesNo |
If Yes, please state WHEN
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WHERE
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WHAT decision was made?
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| COMPLAINT INFORMATION |
Please explain your complaint: Try to be brief, but be sure to tell WHAT happened, WHEN it happened and WHERE it happened. Be specific about any oral statements the business made to you, ESPECIALLY those that influenced you to deal with the company. Describe events in the order in which they happened, referring to all contracts, letters, receipts, cancelled checks, advertisements or other papers that will support your claim. If you have documents or other evidence to support your complaint, it will save time if you print out the pdf complaint form from complete it and mail it to the office with all documentary and other materials related to your complaint.
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What would you like the business to do to settle your complaint?
PLEASE READ CAREFULLY
The Higher Education Bureau cannot act as your private attorney.
The Higher Education Bureau provides a mediation service to consumers where an attempt may be made to mediate your individual consumer complaint if it falls within the jurisdiction of the office. Please be advised that the information you provide will be shared with the party against which you have filed a complaint. Additionally, your complaint may be shared with or referred to other Governmental Law Enforcement or Regulatory Agencies.
Your complaint will also be kept on file with our office and the information contained therein may be used to for future use. Attached to this complaint form is an informational sheet, which will help you in completion of the complaint form and also will explain in greater detail the mediation process.
By completing and submitting this complaint form, I am adopting this as my online signature and I authorize the Higher Education Bureau to contact the party (ies) against which I have filed a complaint in an effort to reach an amicable resolution. I further authorize the party (ies) against which I have filed a complaint to communicate with and provide information related to my complaint to the Higher Education Bureau. I verify that I have read and understand the informational sheet about this process; and, that the information provided is true and correct to the best of my knowledge, information and belief.
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