Form En-651-300 - Complaint Form
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1Complaint Form
Board of Registration for
STATE OF WASHINGTON
STATE OF WASHINGTON
Department of
Department of
Professional Engineers and Land Surveyors
Complete all sections; attach statement
PO Box 9649
describing complaint; sign, date, and submit.
Olympia, WA 98507-9649
(360) 664-1571, FAX (360) 664-2551
Complainant Information
Complainant’s name
Home phone
(
)
Street address
Work phone
(
)
PO Box (if any)
Fax number
(
)
City
State
Zip code
Licensee Information
Licensee’s name
Home phone
(
)
Business name
Work phone
(
)
Street address
Fax number
(
)
PO Box (if any)
City
State
Zip code
Communications
If you answer “Yes” to any or the following questions, please provide details in your complaint.
Have you attempted to resolve your complaint with the licensee?
Yes
No
Did you advise the licensee that you were considering filing a complaint with the Board?
Yes
No
Was another engineer or land surveyor consulted about the problem?
Yes
No
Complaint Description
Attach a statement describing your complaint. Be specific. Describe what work the licensee was hired to perform;
the project location; the problem(s) encountered; who else is involved (names, addresses, telephone numbers); specific
dates and details. Include copies of plans, maps, contracts, and any other information that you believe will support your
complaint. If submitting photographs, be sure they are in color or colored photocopies.
Remedy Requested
Please specify the remedy or result you are requesting from the Board
Please note: Washington State laws do not grant the Board authority or jurisdiction over civil matters (such as fees charged,
contract disputes, or property line ownership disputes). On those issues, it is suggested that you consult legal advice.
Signature
I certify (or declare) under penalty of perjury under the laws of the State of Washington that the foregoing and any
attachments hereto, which are incorporated herein by reference, are true and correct.
X
Signature______________________________________________________________ Date ____________________
Printed name ____________________________________________________ County ________________________
The Department of Licensing has a policy of providing equal access to its services. If
you need special accommodation, please call (360)664-1571 or TDD (360)586-2788.
EN-651-300 COMPLAINT FORM (R/4/00)FM/W
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