STATE OF CALIFORNIA - STATE AND CONSUMER SERVICES AGENCY …

STATE OF CALIFORNIA - STATE AND CONSUMER SERVICES AGENCY                                                                           ARNOLD SCHWARZENEGGER, GOVERNOR


                                                BUREAU OF ELECTRONIC AND APPLIANCE REPAIR
                                                                        3485 Orange Grove Avenue, Suite A
                                                                           North Highlands, CA 95660
                                                                       (916) 574-2069 Fax: (916) 574-2120
                                                                                 www.bear.ca.gov


                                              Electronic and Appliance Repair
                                                    Industry Tip Form
Your Information:                                                                         Tip About:
 CONTACT NAME                                                                         COMPLAINT FILED AGAINST (RESPONDENT):                        LICENSE/REG. NO IF KNOWN




 BUSINESS NAME                                                                        ADDRESS         (NUMBER)          (STREET)




                                                                                          (CITY)                   (STATE)           (ZIP CODE)
 ADDRESS



 (CITY)                 (STATE)               (ZIP CODE)                              PHONE NUMBER




 PHONE           DO YOU WANT TO REMAIN ANONYMOUS?    YES     NO                       PERSON DEALT WITH:




 Your Email Address:             ________________________________________________Your Fax Number:                ____________________________________________

 PLEASE SPECIFY TYPE OF COMPLAINT:
    Parts Availability             Literature Availability        Unregistered Activity            Advertising Issues          Other _______________________
 For Parts/Availability Tips: Are you a Manufacturer-authorized service?     Yes           No
 Please provide the following:
 Model Number(s) of Set(s)                                                            Date(s) of Manufacture




 Please attach any supporting documents but do not provide originals. Documents provided will not be returned.


          Summary of the issue(s)
          Copy of any relevant correspondence (e.g., letters to Manufacturer)
          Copies of any invoices related to the issue(s)
          Copies of advertisements (for unregistered or advertising issues)
          Any other documentation


 Please send information to:
              BEAR
              Field Operations
              3485 Orange Grove Avenue, Suite A
              North Highlands. CA 95660                                    Or fax to: (916) 574-2120 ­ Attn: Field Operations




               ________________________________________________                                                        _________________________________
               Signature                                                                                               Date



          The information collected on this form is collected pursuant to Sections 325, 326 and 9812 of the Business and
          Professions Code. For questions regarding the use of your personal information please review the attached
          departmental notice regarding the collection and use of personal information.
                        Notice on Collection of Personal Information

Collection and Use of Personal                         may include sharing any personal
Information. The Bureau of Electronic and              information you gave us.
Appliance Repair of the Department of
Consumer Affairs collects the information              The information you provide may also be
requested on this form as authorized by                disclosed in the following circumstances:
Business and Professions Code Sections 325             ·   In response to a Public Records Act
and 326. The Department uses this                          request, as allowed by the Information
information to follow up on your complaint.                Practices Act;
                                                       ·   To another government agency as
Providing Personal Information Is                          required by state or federal law; or
Voluntary. You do not have to provide the              ·   In response to a court or administrative
personal information requested. If you do                  order, a subpoena, or a search warrant.
not wish to provide personal information,
such as your name, home address, or home               Contact Information
telephone number, you may remain                       You have a right of access to records
anonymous. In that case, however, we may               containing personal information about you
not be able to contact you or help you                 maintained by the Department of Consumer
resolve your complaint.                                Affairs, unless the records are exempted
                                                       from disclosure by Section 1798.40 of the
Possible Disclosure of Personal                        California Civil Code. Individuals may
Information.                                           obtain information regarding the location of
We make every effort to protect the personal           his or her records by contacting the Public
information you provide us. In order to                Records Request Coordinator at the
follow up on your complaint, however, we               following address and telephone number:
may need to share the information you give             3485 Orange Grove Ave., North Highlands,
us with the business you complained about              California, 95660 or (916) 574-2041.
or with other government agencies. This




                                    Privacy Notice for Complaints