Complaint Form - PBA | Society of Canada

Complaint Form

PLEASE ENTER YOUR PERSONAL INFORMATION TO INITIATE A COMPLAINT

First Name *

Last Name *

Your Address

Address Line 1 *

Address Line 2

City *

Country *

Province/State *

Province/State

Postal/Zip *

Primary Number *

Primary Email *

PLEASE ENTER THE INFORMATION OF THE LICENSEE YOU WOULD LIKE TO MAKE A FORMAL COMPLAINT ABOUT

First Name *

Last Name *

Business Name

Date incident happened *

PLEASE ENTER YOUR COMPLAINT *

Would you be willing to appear before a committee of enquiry if requested?

Enquiry *

Yes

Your Signature *

Date Submitted *