Complaint Form | Mississippi State Board of Cosmetology

One of the principal duties of the Mississippi State Board of Cosmetology is to investigate any alleged violations of the Cosmetology Laws of the State of Mississippi, Title 73, Code of 1972, and violations of the Rules and regulations of the Board.

The Board will not complete an investigation without the receipt of a written complaint, verified and sworn to under oath.

To file a complaint online, please submit the form below. All fields marked with an * are required.

IT IS A CRIME TO KNOWINGLY FILE A FALSE STATEMENT UNDER OATH

COMPLAINT

I hereby affirm under oath, the following:

My name is*
My address is*
My telephone number is*
My email address is*
My complaint is against*
Their address is*
Their phone number is*

My grievance is as follows*

Supplemental Files (as needed):

I realize this complaint is a public record that may be releasedYesNo
I realize that my name may be realized to the accused.YesNo
I realize that I may be required to testify in any hearing(s) or other proceeding(s) that may result.YesNo

AUTHORITY TO RELEASE/OBTAIN INFORMATION

I*, , hereby authorize the Mississippi State Board of Cosmetology to take the following actions:

1. Talk to anyone who can provide information pertaining to my complaint;
2. Access and review any and all information regarding me and my complaint.

I understand this consent will expire twelve months from the date of my signature, and cannot be renewed without my written consent.

Complainant*
Date*

COMPLAINANT IDENTIFYING DATA

Last Name*
First Name*
Maiden, if applicable
Sex*
Date of Birth*
County*
Street Address*
City*
State*
Zip*

CONSENT TO TESTIFY

I*, , hereby consent and bind myself to appear before the Mississippi State Board of Cosmetology and any court of law to testify to the complainant allegations, and I understand that the information becomes public record once filed with the Board, and the investigation is over.

Complainant*
Date*

COMPLAINANT IDENTIFYING DATA

Last Name*
First Name*
Maiden, if applicable
Sex*
Date of Birth*
County*
Street Address*
City*
State*
Zip*