P.O. Box 980818
West Sacramento, CA 95798-08
18
Phone: (916) 574-890
0 or (888) 370-7589
Fa
x: (916) 263-189
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www.bppe.ca.go
v
COMPLAINT FORM
To file a complaint against a private postsecondary institution subject to the laws of the California
Postsecondary Education Act, please complete and submit this form, along with all supporting
documents, to the Bureau for Private Postsecondary Education at the address or fax number listed
above. The text of the Act and corresponding regulations is available on the Bureau for Private
Postsecondary Education’s (BPPE) website at www.bppe.ca.gov.
(Please type or write legibly in ink)
COMPLAINT FILED AGAINST
NAME OF SCHOOL
ADDRESS PHONE NUMBER
CITY STATE ZIP
PERSON FILING COMPLAINT
Your Relationship to the School:
☐ Student Former ☐ Current Employee ☐ Veteran ☐ Licensee G y
☐
☐ overnment Agenc
Other: ___________________________
California Resident? ☐ Yes ☐ No
California Resident during time of attendance? ☐ Yes ☐ No
Are you currently or have you previously served in the Military? ☐ Yes ☐ No
LAST NAME FIRST MIDDLE INITIAL
MAILING ADDRESS
CITY STATE ZIP
DAYTIME TELEPHONE EVENING TELEPHONE EMAIL ADDRESS
STUDENT FUNDING/LOAN INFORMATION
Do you have a student loan agreement/contract with the school? ☐ Yes ☐ No
If yes, what form of payment(s) have been made to the institution on your behalf?
State funds (Program Name): _________________________________________________________
Federal Financial Aid funds (Program Name): ____________________________________________
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☐ Workers’ Compensation funds ☐ US Department of Education ☐ Private Funding
☐ Other, please specify: ______________________________________________________________
☐
Military Education/VA Benefit Funds (Title 38). If so, are you: ☐ Service person/veteran receiving
benefit ☐ Eligible family member/beneficiary
Did you receive funds in the form of Voucher/s? ☐ Yes ☐ No
DETAILS OF COMPLAINT
Are you filing a complaint on behalf of someone else?
☐
Yes ☐ No
Name of student if different from person filing complaint:
Last Name: __________________________________ First Name: ____________________________
Middle Initial: ___________
Telephone Number of Student: _____________________________________________________
___
Email Address of Student: ____________________________________________________________
Relationship to Student: ______________________________________________________________
Student Status:
☐ Currently Attending ☐ Terminated ☐ Withdrew ☐ Graduated ☐ Other: ____________________
Educational Program: ________________________________________________________________
Date of Enrollment: _____________________________
Have you or do you intend to file a complaint with any other entity regarding this matter?
☐ Yes ☐ No
If yes, provide the following information:
Name of Entity: __________________________
___________________________________________
Name of Contact Person: _____________________________________________________________
Telephone Number: _____________________________
Date Complaint Filed: ___________________ Status of Complaint: ____________________________
Have you attempted to resolve this matter with the school?
☐
Yes
☐
No
If yes, with whom did you speak, what was the date(s) of the conversation, and
what was decided?
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DETAILS OF COMPLAINT (continued)
Describe your complaint in detail, including dates, and your requested resolution. Attach
additional pages if needed, along with supporting documents.
Evidence/Documents Provided: ☐ Enrollment Agreement
☐
Student Catalog ☐ Proof of
Payments or educational debt incurred
☐
Other: _________________________________________
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Continued:
NOTICE ON COLLECTION OF PERSONAL INFORMATION
Collection and Use of Personal Information.
The Department of Consumer Affairs and the Bureau for Private Postsecondary Education (BPPE)
collects the information requested on this form to follow up on your complaint.
Providing Personal Information Is Voluntary.
You do not have to provide the personal information requested. If you do not wish to provide personal
information, such as your name, home address, or home telephone number, you may remain
anonymous. However, the BPPE Complaint Investigations Unit may not be able to contact you and/or
assist you in resolving your complaint.
Access to Your Information.
You may review the records maintained by the BPPE that contain your personal information, as
permitted by the Information Practices Act. See below for contact information.
Possible Disclosure of Personal Information.
We make every effort to protect the personal information you provide us. In order to follow up on your
complaint, however, we may need to share the information you give us with the school you complained
about or with other government agencies. This may include sharing any personal information you gave
us.
The information you provide may also be disclosed in the following circumstances:
• In response to a Public Records Act request, as allowed by the Information Practices Act;
• To another government agency as required by state or federal law;
• In response to a court or administrative order, a subpoena, or a search warrant.
Contact Information
For questions about the Department of Consumer Affairs’ privacy policy or the Information Practices
Act, contact the Office of Privacy Protection, 1625 N. Market Blvd., Sacramento, CA 95834, or email
[email protected]a.gov.
I declare under penalty of perjury that the forgoing statement and attachments are true and
correct to the best of my knowledge.
Signature of Complainant
_______________________________________________________________________________________________
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