Statement of complaint: State the details of your complaint, including the dates on which acts pertaining to your complaint
occurred and the names of any witnesses. Please also state how you wish this complaint to be resolved. Attach additional
pages if more space is needed.
Witness to statement: After completing your statement of complaint, complete the following in the presence of a Notary
Public:
Name of employee filing complaint (please print) Telephone number
Signature of employee filing complaint Date
To be completed by the Notary Public:
State of Texas, County of _____________________. On this the____ day of ____________________, ______, personally appeared
___________________________________, and, having been duly sworn, subscribed to the foregoing Complaint Form, and stated
that the facts set forth therein are true.
Notary Public signature
Received by: After the Notary Public signs the form, deliver the form to the Director, Human Resources.
Through:
Director, Human Resources (please print) Signature Date received
Through:
Department Head (please print) Signature Date received
To:
Senior Administrator (please print) Signature Date received
Refer to System Regulation 32.01.02, Complaint and Appeal Procedure for Nonfaculty Employees.
HR 40 (7/07)
The Texas A&M University System
System Offices
Complaint Form
Original Signature Required
Original Signature Required
