Filing a Complaint - Louisiana Board of Examiners in Dietetics and

LOUlSIANA BOARD OF EXAMINERS IN DIETETICS AND NUTRITIONISTS
COMPLAINT FORM
Person Registering Complaint
Name_________________________________
Telephone (
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Address _______________________________________________________________
City, State, Zip __________________________________________________________
Person Complaint Registered Against
Name_________________________________
Telephone (____) ______________
Address _______________________________________________________________
City, State, Zip __________________________________________________________
Is the individual license by this Board?
____ Yes ____ No ____ Unknown
Details of Complaint: Multiple pages may be necessary. If so, please sign and date each one.
Include specific details such as names, dates and particulars about the alleged violation(s), or any
other pertinent facts. Please submit complaints in a legible format, preferably typed.)
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Complaint Form
Page 2
Details of Complaint Continued:
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I, the undersigned, by filing this complaint, do authorize the Louisiana Board of Examiners in
Dietetics and Nutrition to investigate and resolve this matter in accordance with the Board’s Rules
and Regulations.
Signature: _______________________________________ Date: ___________________________
For office use only:
Complaint No.:__________
Date Received:_________