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<html>
<head>
<meta HTTP-EQUIV="Content-Type" CONTENT="text/html; iso-8859-1">
<meta name="GENERATOR" content="Microsoft FrontPage 3.0">
<title>CCB/LCB Feedback Form</title>
<meta name="Microsoft Theme" content="polar 000, default"><meta name="Microsoft Border" content="none"></head>
<body bgcolor="#FFFFFF" text="#000033" link="#0000CC" vlink="#333399" alink="#6600FF"><!--mstheme--><font face="arial, helvetica">
<p align="center"><big><strong>How are we doing?</strong></big></p>
<p><small>Do you have any suggestions to improve our service to you?</small></p>
<p><small>If you have a suggestion about how we, the CCB,&nbsp; can improve our service to
you, please let us know.&nbsp; Or, if you have a compliment for one of our staff members,
here's the place to do it.</small></p>
<p><small><strong>This e-mail form cannot be used for official CCB business. &nbsp; Please
use appropriate agency Registration/Renewal, Claims Resolution, Enforcement or Hearings
documents for other CCB business (see <a href="asp/publicat.htm">Publications and Forms</a>).
&nbsp; If you have a general inquiry about the CCB, submit your question to <a href="mailto:ccbinfo@ccb.state.or.us" alt="E-mail a question or comment to the CCB">ccbinfo@ccb.state.or.us</a></strong>.
&nbsp; <strong>If you have a general inquiry about the LCB, submit your question to</strong><a href="mailto:lcbinfo@ccb.state.or.us" alt="E-mail a question or comment to the CCB"> <strong>lcbinfo@ccb.state.or.us</strong></a>.&nbsp;
</small><br>
<font color="#FF0000"><em><strong><small>You will receive no response to comments
submitted via this form.</small><br>
</strong></em></font></p>
<form METHOD="POST" action="_vti_bin/shtml.dll/feedback.htm" webbot-action="--WEBBOT-SELF--">
<!--webbot bot="SaveResults" S-Email-Format="TEXT/PRE" S-Email-Address="ridgwab@ccb.state.or.us" B-Email-Label-Fields="TRUE" S-Builtin-Fields="Date Time REMOTE_NAME REMOTE_USER HTTP_USER_AGENT" startspan --><input TYPE="hidden" NAME="VTI-GROUP" VALUE="0"><!--webbot bot="SaveResults" endspan i-checksum="43374" --><p><small>What Board do you want to comment on?&nbsp;&nbsp; <select NAME="Board" size="1">
<option selected value="CCB">CCB</option>
<option value="LCB">LCB</option>
</select></small></p>
<p><small>What do you want to comment on?&nbsp;&nbsp;&nbsp; <select NAME="InitialComment" size="1">
<option SELECTED>Claims </option>
<option>Enforcement </option>
<option>Registration </option>
<option>Staff </option>
<option>Publications </option>
<option>Web Site </option>
<option>Other </option>
</select> </small></p>
<p><small>Other:&nbsp;&nbsp;&nbsp; <input TYPE="TEXT" NAME="OtherSubject" SIZE="20" MAXLENGTH="20"></small></p>
<p><small>Enter your comments in the space provided below.</small></p>
<blockquote>
<p><small><textarea rows="4" name="Comments" cols="50"></textarea> <br>
</small></p>
</blockquote>
<p><small>Did your contact/involvement with the agency have to do with:</small></p>
<blockquote>
<p><small><input TYPE="RADIO" NAME="Agencycontact" VALUE="Registration (including bond, insurance, education, etc.)?" CHECKED> Registration
(including bond, insurance, education, etc.)? <br>
<input TYPE="RADIO" NAME="Agencycontact" VALUE="A law violation or enforcement issue?"> A
law violation or enforcement issue? <br>
<input TYPE="RADIO" NAME="Agencycontact" VALUE="A claim?"> A claim? <br>
<input TYPE="RADIO" NAME="Agencycontact" VALUE="Other?">Other:&nbsp;<input TYPE="TEXT" NAME="Contactother" SIZE="20" MAXLENGTH="20"></small></p>
</blockquote>
<div align="center"><center><!--mstheme--></font><table border="0" width="100%">
<tr>
<td width="25%"><!--mstheme--><font face="arial, helvetica"><strong><small>How would you rate our:</small></strong><!--mstheme--></font></td>
<td width="14%" align="left"><!--mstheme--><font face="arial, helvetica"><!--mstheme--></font></td>
<td width="14%" align="left"><!--mstheme--><font face="arial, helvetica"><!--mstheme--></font></td>
<td width="47%" align="left"><!--mstheme--><font face="arial, helvetica"><!--mstheme--></font></td>
</tr>
<tr>
<td width="25%"><!--mstheme--><font face="arial, helvetica"><!--mstheme--></font></td>
<td width="14%" align="left"><!--mstheme--><font face="arial, helvetica"><small><strong>Service:</strong></small><!--mstheme--></font></td>
<td width="14%" align="left"><!--mstheme--><font face="arial, helvetica"><small><strong>Courtesy:</strong></small><!--mstheme--></font></td>
<td width="47%" align="left"><!--mstheme--><font face="arial, helvetica"><small><strong>Timeliness:</strong></small><!--mstheme--></font></td>
</tr>
<tr>
<td width="25%"><!--mstheme--><font face="arial, helvetica"><!--mstheme--></font></td>
<td width="14%" align="left"><!--mstheme--><font face="arial, helvetica"><small><input TYPE="RADIO" NAME="Service" VALUE="Excellent" CHECKED> Excellent </small><!--mstheme--></font></td>
<td width="14%" align="left"><!--mstheme--><font face="arial, helvetica"><small><input TYPE="RADIO" NAME="Courtesy" VALUE="Excellent" CHECKED> Excellent </small><!--mstheme--></font></td>
<td width="47%" align="left"><!--mstheme--><font face="arial, helvetica"><small><input TYPE="RADIO" NAME="Timeliness" VALUE="Excellent" CHECKED> Excellent</small><!--mstheme--></font></td>
</tr>
<tr>
<td width="25%"><!--mstheme--><font face="arial, helvetica"><!--mstheme--></font></td>
<td width="14%" align="left"><!--mstheme--><font face="arial, helvetica"><small><input TYPE="RADIO" NAME="Service" VALUE="Good"> Good </small><!--mstheme--></font></td>
<td width="14%" align="left"><!--mstheme--><font face="arial, helvetica"><small><input TYPE="RADIO" NAME="Courtesy" VALUE="Good"> Good
</small><!--mstheme--></font></td>
<td width="47%" align="left"><!--mstheme--><font face="arial, helvetica"><small><input TYPE="RADIO" NAME="Timeliness" VALUE="Good">
Good </small><!--mstheme--></font></td>
</tr>
<tr>
<td width="25%"><!--mstheme--><font face="arial, helvetica"><!--mstheme--></font></td>
<td width="14%" align="left"><!--mstheme--><font face="arial, helvetica"><small><input TYPE="RADIO" NAME="Service" VALUE="Fair"> Fair </small><!--mstheme--></font></td>
<td width="14%" align="left"><!--mstheme--><font face="arial, helvetica"><small><input TYPE="RADIO" NAME="Courtesy" VALUE="Fair"> Fair
</small><!--mstheme--></font></td>
<td width="47%" align="left"><!--mstheme--><font face="arial, helvetica"><small><input TYPE="RADIO" NAME="Timeliness" VALUE="Fair">
Fair </small><!--mstheme--></font></td>
</tr>
<tr>
<td width="25%"><!--mstheme--><font face="arial, helvetica"><!--mstheme--></font></td>
<td width="14%" align="left"><!--mstheme--><font face="arial, helvetica"><small><input TYPE="RADIO" NAME="Service" VALUE="Poor"> Poor </small><!--mstheme--></font></td>
<td width="14%" align="left"><!--mstheme--><font face="arial, helvetica"><small><input TYPE="RADIO" NAME="Courtesy" VALUE="Poor"> Poor
</small><!--mstheme--></font></td>
<td width="47%" align="left"><!--mstheme--><font face="arial, helvetica"><small><input TYPE="RADIO" NAME="Timeliness" VALUE="Poor">
Poor </small><!--mstheme--></font></td>
</tr>
</table><!--mstheme--><font face="arial, helvetica">
</center></div><p><small>Did one of our employees make an extra effort to serve you or do
you have a suggestion to help us serve you better in the future?</small></p>
<blockquote>
<p><small><textarea rows="4" name="Effort" cols="50"></textarea> <br>
</small></p>
</blockquote>
<p><small>Other comments?</small></p>
<blockquote>
<p><small><textarea rows="4" name="OtherComments" cols="50"></textarea> <br>
</small></p>
</blockquote>
<p><small><input TYPE="SUBMIT" VALUE="Submit Form"> <input TYPE="RESET" VALUE="Reset Form">
</small></p>
</form>
<p>&nbsp;</p>
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</html>