Complaint Form Confirmation

Reference #: Date Received: 02/04/12

Thank you for your input. Your complaint has been received by the CLTC Board of Standards, Inc. Please use the reference # above when inquiring about you case. To contact the Board please call (314) 520- 3564 or email Joan Hecker at: joan_hecker@sbcglobal.net.

Please allow 15 – 60 days to receive a decision about your case from the Board of Standards.

All fields marked with a "*" are required:

Date	02/04/12
Name *
Address *
City *
State *
Zip *
Daytime Phone *
Email Address *
Graduate's Name (person being reported) *
Graduate's Company/Affiliation *
Name of Insured (if applicable)
Policy Number(s)/Company (if applicable)
Please describe your complaint below: *
Please enter the code that's displayed in the image: *

Authorization: *

By checking here, I recognize that the CLTC Board of Standards, Inc. will review this complaint and may initiate an investigation which would include providing a copy of this complaint form and all attachments to the CLTC designee that is the subject of my complaint.