BLCE Online Complaint Form PSP LCE - Complaint Submission :: Survey Form
All information submitted is confidental and complaints may be submitted anonymously.

If you chose to provide contact information you may be contacted for additional information.
1. Name of Establishment or Business:*
2. Names of indvidual(s) involved:
3. Establishment Street Address:
4. Establishment City or Town:
5. Zip Code:
6. County:*
7. Township:
8. Please provide a brief discription of the observed or suspected violations:*

Please provide your contact information in blocks 9-12:
(All information will be kept confidential and will assist the investigator)
9. Name:
10. Full Address:
11. Daytime Telephone:
12. Email Address: