DEPARTMENT OF LAW

Division of Consumer Affairs

Complaint Form Page 1 of 4

NOTE:
This is a FOUR(4) page form, you MUST complete all FOUR pages. Fields marked in green and/or with an asterisks (*) are required. The information you provide may be sent to the person or firm you are complaining against. You will have the opportunity to print the form for your records after the final submission.

IMPORTANT:
When you have completed the form you will receive an email asking you to verify the submission. If you do not verify the submission within 14 days then your information will be deleted.

1. Complainant
First Name:	*
Last Name:	*
Home Address:	*
Address (line 2)
City:	*
State:	* Zip Code: *
Home Phone:	* Best time to call:
Email Address:	*
Confirm Email Address:	*
Work Phone:	Can we call at work? Yes No

	Atlantic County Division of Consumer Affairs 1333 Atlantic Avenue - 8th Floor Atlantic City, New Jersey, 08401