Name of Complaint

Complainant's position in Company

Complainant's Company/Employer:

Nature of Company/Employer Business:

Complainant's Address

Complainant's Telephone Number

Complainant's Email Address:

Date of Complaint

Isolated/Repetitive Incident:

Name of Individual subject to complaint:

NIPCS Number of individual:

The nature of complaint:

Technical

Code of conducts

Is the complaint to do with IPCS remote examination centre:(if YES please state location)

If you are making a complaint against an individual within IPCS administrative body, please complete below: (Name of individual the complaint about)

Summary of complaint:

Signature of Complaint:

Date: