Day Phone

Evening Phone

Email

Preferred method for contacting you:
Day Phone
Evening Phone
Email

Information about the Company involved in your allegation(s)

Name of Company

Contact person (if known)

Address (Street or P.O. Box)

City

State

Zip Code

Day Phone

E-mail address if known:

Do you know if this company is currently a member of CALSEIA?
Yes    No

Information about your specific allegation(s)
Please outline the specific nature of the allegation(s) in sufficient detail to fully understand and appreciate your situation. Include information about timing, contract length, financial arrangements, and any other information you feel will assist CALSEIA in investigating your allegation(s). Describe, for each allegation, the “what, when, where, who, why and how” of the situation, preferably in chronological (over time) order.

Attach copies (only) of any documents that you feel would help CALSEIA understand your allegations. (Retain ALL originals of your documents for your files. If you do not have electronic copies of documents, please make copies and mail the copies to CALSEIA.)

Information about the Company relationship
How did you find this company?

Did you hire this company?
Yes    No

Dates of hire: From   To  

How did you select this company?

What agreements did you have with this company?

Were there written agreements or a written contract?
Yes    No

If you answered Yes above, please attach an electronic copy of the written agreement or written contract

Comments:

Actions you have taken to resolve your disagreement with this Company

What resolution alternatives have you and the company discussed to date?

What has been missing from these attempts at conflict resolution that caused you to initiate this complaint to CALSEIA at this time?

State below any other actions you have taken to resolve this complaint and the outcomes.

Please describe your ideal resolution of this situation.

Please describe what you feel would be an acceptable resolution of this situation.

Please complete the following authorization for us to proceed with investigation:

I, _______declare the facts that I have stated herein to be true and the supporting documentation I am submitting to be authentic to the best of my knowledge. I hereby authorize the Ethics Committee of CALSEIA to review my request and communicate this information to involved parties. I understand that:

(1) the Ethics Committee of the CALSEIA cannot guarantee any outcome, and is therefore held harmless of said outcome;
(2) the Ethics Committee of CALSEIA is not a court of law and CALSEIA, the Ethics Committee of CALSEIA and their agents cannot act as my attorney.

I understand I will be contacted by a CALSEIA representative within two weeks after this completed Complaint Form is received by CALSEIA.

Signature of Complainant:

Date: