160 East 300 South, PO Box 146711, Salt Lake City, UT 84114-6711
Telephone (801) 530-6747 • Facsimile (801) 526-4387 • Internet: www.realestate.utah.gov
State of Utah
Department of Commerce
Division of Real Estate
CE BANKING COMPLAINT FORM
Please complete (type or neatly print), sign and submit this form along with a copy of course certificate by fax, mail, or in person.
Complaint Type: ( ) Appraisal ( ) Mortgage ( ) Real Estate
I. YOUR INFORMATION Request Confidentiality? Yes No
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Your Name Home Phone Work Phone Cell Phone
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Mailing Address City State Zip
II. COURSE INFORMATION
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Name of course completed Date course was completed
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Name of education provider
Have you previously contacted the provider about this course not being banked? Yes No
If yes, what was their response:
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If you have any other comments or complaints about the provider, please explain:
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I hereby certify that the information provided is correct to the best of my knowledge and I recognize that this information, including
my name, may become part of the public record should a case be brought before the appropriate regulatory Board/Commission.
Signature ___________________________________________________ Date ______________________________