Complaint Form

(Please Print or Type)

Date: / /

Attention: Board Secretary/Treasurer

I respectfully submit this complaint to the Board and request that they accept it as a matter within its jurisdiction and responsibility. If this complaint is assigned for investigation. I agree to cooperate fully with such investigation and to permit the Board investigator to see and/or copy any documents necessary for a complete investigation.

COMPLAINANT (Person filing complaint):		COMPLAINT IS AGAINST:


Your name (in print)		Name of individual and license/registration, if known

Street Address		Business name, if any

		Street Address

City, State, Zip Code

Daytime Telephone / FAX Number		City, State, Zip Code

Home or Evening Telephone		Daytime Telephone / FAX Number

E-mail Address (if any)		E-mail Address or Website (if known)

1. My problem is:	Service
	Unlicensed Practice
	An issue, incident, or violation of statue, rules and regulations

2. Complaint Details:

I paid a fee for services rendered. Yes, $ on (Date) / / No

Specific dates of service provided. From / / To / /

I made a complaint to the individual(s) involved by:

	Telephone on (date/s)
	Regular Mail on (date/s)
	E-mail on (date/s)

3. DESCRIPTION OF YOUR COMPLAINT: Be specific. Who else is involved? Give names, addresses and telephone numbers of any witnesses or persons you dealt with. Give dates and details of your contacts. Include copies of ALL documents including plans, maps, letters, contracts, etc. relative to the complaint. If there is no written contract, provide details of the agreement. Attached additional sheets if space is insufficient.

4. WHAT DO YOU WANT THE BOARD TO ACCOMPLISH IN RESOLVING YOUR COMPLAINT?

5. DECLARATION

I declare, under penalty of perjury, that the information contained in this complaint (including any attached pages) is true and correct to the best of my knowledge and belief.

I agree that all documents in this complaint will be a public record once the complaint is deemed to have merit.

Signature:

Date: / /

*********************************************THIS PORTION FOR OFFICE USE ONLY*********************************************

CASE NUMBER :		Date Closed:	/ /
Date Opened :	/ /
License Number :
Expiration Date :	/ /

Violation



Board Action