Ombudsman Request Form Back to Professional Standards Printable PDF Form Ombudsman Request Form Complainant's Information Name: * Name of Complainant - First and Last Firm (if any): * Email Address: * A copy of this form will be sent to this email address. Phone Number: * Preferred number for contact Best time to contact you: * Mailing Address * Mailing Address Street Address Street Address Apartment/Suite # (Optional) Apartment/Suite # (Optional) City City State State Zip Zip Role in Transaction: * (ex: buyer, seller, agent, broker) Subject property (if any): * Respondent's Information Name of Respondent * First and Last Firm: * Respondent's Address * Respondent's Address Street Address Street Address Apartment/Building/Suite # (Optional) Apartment/Building/Suite # (Optional) City City State State Zip Zip Respondent's Phone Number * Role in Transaction: * (ex: listing agent, selling agent, broker) What issue would you like the Ombudsman to resolve? * * All information on this form is confidential. The Medina County Board of REALTORS® will destroy this form and any other documents and materials pertaining to this matter at the conclusion of the ombudsman services. Submit