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Name:
Student ID Number:
Address:
Phone Number:	( ) - Second three digits Last four digits
Phone Number Type:	Home Work Cell
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Nature of Complaint

Date of Event:

The date the incident occurred.

Department or Staff Involved:

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Description of Complaint:

Please include the names and departments of any staff members involved in the incident.

Describe Any Effort You Have Made To Resolve The Issue:

What is a Fair Resolution to Your Problem?:

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Answer the question below:

Is seven > than eight? (true/false)

Please enter the security code to complete your application.
Please answer with either a number (ex. 7) or with the words “true” or “false”

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Los Angeles City College | 855 N. Vermont Avenue, Los Angeles California 90029

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Phone: 323.953.4000

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Emergency: 323.953.2911