Provide a detailed description of the incident that lead to the action being taken against you including the date of the incident :
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Describe the nature of the complaint and provide a detailed description of the incident that resulted in the complaint including
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Describe the specific action(s) taken against you (for example - did you have a permit revoked, paid a fine, had a state license disciplined, had your
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The stated reason for the action being taken against you (for example – a massage professional failed to properly cover a client, the business used an un-permitted or un-certified person to provide
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Identify who made the complaint (for example – the client, the spouse of a client, the parent of a client,
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Identify who the complaint was made against (for example – you, a massage professional working at
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List all locations, dates and periods of registration below. Use the 'Add' button for each registration :
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Please also provide copies of any documentation you have in relation to the action taken against you (for example – copies of administrative citations, judgments, receipts for fines paid, final decision letters from the agency that took action against you, etc.).
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