Complaint Form

Please provide the board with your contact information:

Name:*

Phone:*

Email:*

Street Address:*

City:*

State:*

Zip:*

Please provide the board with the following information regarding your complaint:

Name:

Mailing Address:

City:

State:

Zip:

Please provide a detailed description of each of the following:

1.Date, time, and place prohibited activity occurred:*

2.Prohibited activity that took place:*

3.Any persons/entities (other than those named above) who were involved in the prohibited activity:*

4.The names of any other witnesses (a consumer, regulatory agency, licensed optician or apprentice, or anyone else with knowledge of the alleged violation):

5.Any documentation that supports the complaint (e.g. a witness statement or patient record); please attach copies:

.pdf, .jpg, .jpeg, .png

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*I certify, under penalty of perjury, all information given here in is true, correct and complete to the best of my knowledge.

Your Signature:*

Date: