| Name and Address of individual against whom complaint is made: |
| Nature of complaint in detail: (attach additional pages as needed.) |
| Witnesses to incident or situation: (give full names and addresses.) |
| NOTE: LICENSEES ARE NOTIFIED WHEN A COMPLAINT IS FILED AGAINST HIS / HER LICENSE. A COPY OF THE COMPLAINT FORM AND ALL SUPPORTING DOCUMENTS ARE SENT TO THE LICENSEE WITH THE LETTER OF NOTIFICATION. |
| Name, address and telephone number of individual making complaint: |
Signature ________________________________
Date ________________________________
Subscribed and sworn to before me this ________________ day of __________________ , 20___.
My commission expires on the ________________ day of __________________ , 20___.
(SEAL)
Notary Public in and for
COUNTY ________________________
STATE _________________________