Form Bl006 – Fill Out and Use This PDF

CITY OF LAS VEGAS	Fax (702) 382-6642
DEPARTMENT OF PLANNING	TDD (702) 386-9108
BUSINESS LICENSING DIVISION	E-mail us at license@lasvegasnevada.gov
333 N. Rancho Dr., 6th Floor
Las Vegas, NV 89106

Report of Unlicensed Business Activity

All complaints must be submitted in writing. Be as complete as possible. For complaints about performance or quality of work or to enforce a contractual arrangement through small claims court, please see the list of regulatory and enforcement agencies on our website at www. LasVegasNevada.gov

Please type or print legibly.

Information about the Offending Business Activity

Name of the offending business:

Street address of the offending business:

Name of business owner or contact person you dealt with:

Offender's business phone:		Other phone or e-mail:

Describe the activity:

Explain how you found the company, product or service. If you have advertisements, business cards or flyers, attach copies

What is the exact nature of your complaint? If you have a written contract, receipts or other documents, attach copies.

Please proved your contact information below.

Name:

Street Address:

City, State & Zip Code:

Contact Phone:		Alternate Phone #:

E-mail Address:

Name of YOUR business, if applicable:

Complaint Form - Form BL006

09/04/2012

List any witnesses or other individuals who may have observed this activity:

Have you contacted or filed complaints with any other agencies?	Yes	No	Is so, please list below.

I hereby affirm that I am 18 years of age or older, that I have personal knowledge of the matter stated herein and that the statements in this report are true.

Printed Name:

Today's Date:

Signature:

Complaint Form - Form BL006

09/04/2012