STATE OF IOWA IOWA ELECTRICAL EXAMINING BOARD COMPLAINT FORM by oqp13905

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									Chester J. Culver                                                                                     Eugene T. Meyer
Governor                                                                                                  Commissioner
Patty Judge                                                                                               Barb Mentzer
Lt. Governor                                                                                          Board Chairperson




                                               STATE OF IOWA
                                      IOWA ELECTRICAL EXAMINING BOARD
                                              COMPLAINT FORM
Please mail to:                                                                     Complaint #___________________
Iowa Department of Public Safety                                                                 (for office use only)
Electrical Examining Board
Wallace State Office Building
502 East Ninth Street
Des Moines, Iowa 50319

Please Print or Type               PERSON REGISTERING COMPLAINT                     Provide all information

Name:                                                                           Home Phone:
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Address:                            Street Address                      Business Phone:
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City                         State                 County                       Zip Code:
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                                     COMPLAINT REGISTERED AGAINST (Licensed Programs)

Name:                                                                           Home Phone:
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Address:                            Street Address                      Business Phone:
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City                         State                 County                       Zip Code:
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                                                  DETAILS OF COMPLAINT

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                                                          (attach additional pages if needed)




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             (Signature)                                                           Date




  IOWA ELECTRICAL EXAMINING BOARD • 502 EAST NINTH STREET • DES MOINES, IOWA 50319 • 1-866-923-1082 • 515-725-6147
                               http://www.dps.state.ia.us/fm/electrician/index.shtml
                          Integrity • Pride/Professionalism • Teamwork • Commitment • Service

								
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