Complaint/Appeal Form

Covered Employee *

Yes

No

Filing an *

Appeal

Complaint

Disciplinary Action *

Date of Discipline/Reprisal *

Month

Day

Year

Agency *

First Name *

Last Name *

Street Address *

City *

State *

Zip *

Home Phone #

Cell Phone #

Email Address *

Description *

In a brief and concise manner, please state the reason you are filing this appeal/complaint by explaining why the allegations against you (appeal) or the prohibited personnel practice taken against you (whistleblower complaint) must be heard by the Arizona State Personnel Board.

Document Preference *

I prefer my appeal/complaint documents to be sent by email.

I prefer my appeal/complaint documents to be sent by mail.

E-Signature *

I Agree

By selecting the "I Agree" button, you are signing this document electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this document. By selecting "I Accept" you consent to be legally bound by this document's terms and conditions. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and the lack of such certification or third party certification will not in any way affect the enforceability of your E-Signature.

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