Florida Business Reply Form

Transcript

1 to: Reply Please Florida Department of Agriculture and FDACS Consumer Services vices Division of Consumer Ser and Mediation Enforcement Division of Consumer Services 2005 Apalachee Parkway Tallahassee, FL 32399- 6500 ADAM H. PUTNAM FLORIDA REPLY FORM BUSINESS www.800helpfla.com COMMISSIONER -FLA (435- 1-800- HELP 7352) FL Only , Florida Statutes Section 570.544(4) 3800 Calling Outside F lorida (850) 410- 5.002 - Rule 5J , Florida Administrative Code Complaint of: __________________________________ Reference No: ____________________________________ Corporate/Legal Name: _______________________________________________________________________________ Fictitious/DBA Name: ________________________________________________________________________________ Principal Address: ___________________________________________________________________________________ Mailing Address (if different): _________________________________________________________________________ nse Number (if applicable): _____________________________________________________________ Registration/Lice Email Address: _____________________________________ Web URL: ______________________________________ Telephone: ________________________________________ FAX: ___________________________________________ Owner’s Name: _____________________________________________________________________________________ Name, title, phone number and email of a person to contact for additional information if necessary: ___ __________________________________________________________________________________________________ Please state your position relative to the complaint. Include any and all relevant facts along with documentation and specifically address any allegations of violations of regulatory rule or law : (estimates, invoices, contracts, etc.) ____________________________________ __________________________________________ Date Signature FDA CS -10983 Rev. 06/15

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