Department of Consumer Affairs (DCA) Assistance Form

Contact Information

First Name *

Last Name *

Address *

City *

Zip Code *

Phone Number

Ext.

Phone Number Type

Request Details

What type of business or profession is this request regarding? *

What do you need assistance with?

Issue with my own license - Please provide: (1) License Number, (2) License Type and (3) Brief Description of Issue

Issue with a licensee (not myself) - Please provide: (1) Name of Licensee, (2) License Number, (3) License Type and (4) Brief Description of Issue

Check the status of a complaint - Please provide: Complaint Number

Other - Please describe

Have you already contacted another elected official for assistance with this issue? *

Yes

If Yes, please list any other elected officials you have contacted.

Authorization for Release of Information

Please carefully read the following:

By completing this form, I am requesting the Office of Assemblymember Bryan (the “Assemblymember”) to assist me in working with the Department of Consumer Affairs (DCA) on my request. I acknowledge that this may require the release of information contained in my records the dissemination of which may be prohibited by law. Therefore, I hereby authorize DCA and the Assemblymember to share all relevant portions of my records with each other, and to discuss matters relating to those records and my request, until my request is resolved.

I agree that I will not submit any personal identifiable information through this form that is not specifically requested. If the Assemblymember’s office needs additional information the office will contact me to request that information. *

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