BLCE Online Complaint Form · Starter Portal

BLCE Online Complaint Form

Name of Establishment or Business

Names of individual(s) involved

Establishment Street Address (e.g. Street Address, PO Box, Company Name, C/O)

Establishment City or Town

Establishment State

Postal Zip Code

Establishment County

Township

Please provide a brief description of the observed or suspected violations (Maximum of 2000 Characters allowed.)

First Name

Last Name

Street Address (e.g. PO Box, Apartment, Suite, Unit, Building, Floor, etc.)

City

Contact State

Postal/Zip Code

Contact Country

Phone: (e.g. XXX-XXX-XXXX)

Enter the code from the image