Company and Individual Information: Name of Unlicensed Individual Name of Unlicensed Company Address City State ZIP Telephone Your Contact Information: Your Name* Your Email* Your Address* City State ZIP Telephone* Date Work Performed *All personal information submitted will remain confidential. Please explain all circumstances surrounding the unlicensed activity witnessed in the area below. Please include supporting documentation such as pictures, signed contracts, cancelled checks, website addresses, social media accounts, etc.
