LOUlSIANA BOARD OF EXAMINERS IN DIETETICS AND NUTRITIONISTS COMPLAINT FORM Person Registering Complaint Name_________________________________ Telephone ( ) 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.) _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ Complaint Form Page 2 Details of Complaint Continued: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 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:_________