Grievance Form

Please read the entire Grievance Form below.

Customer Formal Grievance Form

First Name

Last Name

Street Address

City

State

Zip Code

Phone

Alternate Phone Number

Email Address

Last 4 digits of Social Security #

CareerSource Career Consultant

CareerSource Palm Beach County’s program that you are enrolled in?

CareerSource Palm Beach County Career Center

Central (3400 Belvedere Rd, West Palm Beach FL 33406)

West (1085 S Main St, Belle Glade, FL 33430)

Complaint Information

Date of event(s) resulting in the complaint/grievance?

Complaint Details (Summary of Complaint/Grievance):

ADA accommodation requested in order to participate in the formal grievance process?

Relief requested?

Signature

I hereby authorize the release of any information regarding my complaint to CareerSource Palm Beach County and to the party against whom I have lodged this complaint.

Signature

Sign Here

Date

An equal opportunity/employer program. Auxiliary aids and services are available upon request to individuals with disabilities.