Board of Veterinary Medical Examiners Complaint Form by undul849

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									                                Board of Veterinary Medical Examiners
                                           Complaint Form


Please type or print legibly.
                                        Complainant Information
                                             (Individual filing complaint)

Name: ________

Address:
                           (Number and Street)

City:                                                       State:                 Zip:

Daytime Phone: (           )             -                           Fax: (           )       -

Evening Phone: (           )             -

What is the best way to reach you? □ Daytime Phone □ Evening Phone □ E-mail:____________________



                                             Respondent Information
                                     (Individual the complaint is filed against)

Board or Profession:

Name:                                                                                             _______
                  (Last)                                   (First)                                (Middle Initial)

Business Name:                                                                 __________________________

Address: ______________________________________________________________________
                                     (Number and Street)

City:             _______________________ State: _______________                          Zip Code:         ______

Business Phone: ___ (______) ____________________

Please list all witnesses, providing names, address, and telephone numbers:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
                                        Statement of Complaint

Date and Location of Alleged Violation: _____________________________________________

Please provide a statement of facts, allegations and/or, concerns. Attach a copy of each document
you possess that can substantiate any facts in your complaint. These documents will not be
returned. Please attach additional sheets, if necessary.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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______________________________________________________________________________
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______________________________________________________________________________

Have you attempted to contact the licensee concerning your complaint _______Yes ______No, If
yes? When? ___________________ What was the result?




I attest that the information provided is true, correct, and complete to the best of my knowledge.

_____________________________________                                 ________________________
Complainant Signature                                                           (Date)




                                                For Office Use Only
            Date Received _____/_____/_____                           Receiving Board: __________________
            License Number ______________                             License Type _____________________
            How Received ________________                             Date Received _____/______/________
            Acknowledgement letter sent ____/____/____                Category_________________________




Rev. 2/07

								
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