General Complaint Form

Please complete this form to submit a complaint to Heartland AEA.

Name*
First Last
Email*
Date of complaint*
MM slash DD slash YYYY
Name/Position of person complaint is regarding*
Relationship of complainant to person complaint is regarding*
Description of complaint (Write a brief statement of the complaint including any policies or rules violated where applicable.)*
File upload (if necessary)
Max. file size: 2 MB.
Agreement*
I agree that all of the information on this form is accurate and true to the best of my knowledge.
Date of form submission*
MM slash DD slash YYYY
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