"Official Complaint Form" - Arkansas

Official Complaint Form is a legal document that was released by the Arkansas Veterinary Medical Examining Board - a government authority operating within Arkansas.

Form Details:

  • The latest edition currently provided by the Arkansas Veterinary Medical Examining Board;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Arkansas Veterinary Medical Examining Board.

ADVERTISEMENT
ADVERTISEMENT

Download "Official Complaint Form" - Arkansas

Download PDF

Fill PDF online

Rate (4.8 / 5) 27 votes
STATE OF ARKANSAS
COMPLAINT AGAINST LICENSEE
VETERINARY MEDICAL EXAMINING BOARD
1 NATURAL RESOURCES DRIVE
COMPLAINT AGAINST INDIVIDUAL
P.O. BOX 8505
(If the complaint is being filed for practicing
LITTLE ROCK, AR 72215
veterinary medicine without a license, please
(501) 224-2836
skip #4 below.)
OFFICIAL COMPLAINT FORM
Name of Complainant:
Name of Licensee or Individual:
Address
City
Zip
Address
City
Zip
Home Phone:
Business Phone:
Name of Clinic (if applicable)
Email Address:
INSTRUCTIONS for filing a complaint with the Arkansas Veterinary Medical Examining Board:
1.
Give the full name and address of the licensee or individual that the complaint is against.
2.
Type or print your statement on a separate sheet of paper and attach it to this form.
3.
State facts briefly and clearly.
4.
If the complaint is against a veterinarian, please specify below the violation of the Veterinary Medical
Practice Act and/or Regulations that best applies to this case:
Ark. Code Ann. §17-101-305 of the Veterinary Medical Practice Act consists of the following for
denial, suspension or revocation of a veterinarian’s license (mark only ONE):
1. _____
6. _____
11. _____
16. _____
21. _____
2. _____
7. _____
12. _____
17. _____
3. _____
8. _____
13. _____
18. _____
4. _____
9. _____
14. _____
19. _____
5. _____
10. _____
15. _____
20. _____
If you marked #11 above, please mark below a corresponding Regulation for Unprofessional Conduct
(mark only ONE):
A. _____
E. _____
I. ______
M. ______
B. _____
F. _____
J. ______
N. ______
C. _____
G. _____
K. ______
O. ______
D. _____
H. _____
L. ______
P.
______
STATE OF ARKANSAS
COMPLAINT AGAINST LICENSEE
VETERINARY MEDICAL EXAMINING BOARD
1 NATURAL RESOURCES DRIVE
COMPLAINT AGAINST INDIVIDUAL
P.O. BOX 8505
(If the complaint is being filed for practicing
LITTLE ROCK, AR 72215
veterinary medicine without a license, please
(501) 224-2836
skip #4 below.)
OFFICIAL COMPLAINT FORM
Name of Complainant:
Name of Licensee or Individual:
Address
City
Zip
Address
City
Zip
Home Phone:
Business Phone:
Name of Clinic (if applicable)
Email Address:
INSTRUCTIONS for filing a complaint with the Arkansas Veterinary Medical Examining Board:
1.
Give the full name and address of the licensee or individual that the complaint is against.
2.
Type or print your statement on a separate sheet of paper and attach it to this form.
3.
State facts briefly and clearly.
4.
If the complaint is against a veterinarian, please specify below the violation of the Veterinary Medical
Practice Act and/or Regulations that best applies to this case:
Ark. Code Ann. §17-101-305 of the Veterinary Medical Practice Act consists of the following for
denial, suspension or revocation of a veterinarian’s license (mark only ONE):
1. _____
6. _____
11. _____
16. _____
21. _____
2. _____
7. _____
12. _____
17. _____
3. _____
8. _____
13. _____
18. _____
4. _____
9. _____
14. _____
19. _____
5. _____
10. _____
15. _____
20. _____
If you marked #11 above, please mark below a corresponding Regulation for Unprofessional Conduct
(mark only ONE):
A. _____
E. _____
I. ______
M. ______
B. _____
F. _____
J. ______
N. ______
C. _____
G. _____
K. ______
O. ______
D. _____
H. _____
L. ______
P.
______
Official Complaint Form
Page #2
5.
If the complaint is against a veterinary technician, please specify below the violation of the Veterinary
Medical Practice Act that best applies to this case:
Ark. Code Ann. §17-101-308 of the Veterinary Medical Practice Act consists of the following for
denial, suspension or revocation of a veterinary technician’s certificate (mark only ONE):
1. _____
6. _____
11. _____
2. _____
7. _____
3. _____
8. _____
4. _____
9. _____
5. _____
10. _____
6.
Furnish full names and complete addresses of all persons whom you think can confirm all or part of
your allegations. They may submit statements as well.
7.
Please be sure to give exact dates; if not possible, give month and year.
8.
Enclose a copy of your pet’s medical records from the veterinarian (if applicable).
9.
Board policy states that a complaint must be filed within one year from the time the incident occurred
until the time the complaint is filed.
10.
The owner of the animal must file the complaint. The Board cannot accept a complaint filed by a
second party.
11.
Have this form notarized and return it with ALL information to the Board office.
“I do solemnly swear or affirm that the information given in this affidavit is true, correct and complete
to the best of my knowledge. I hereby authorize the Arkansas Veterinary Medical Examining Board to
verify any and all information contained in this affidavit. This affidavit and signature shall act as
authorization of entities in possession of applicable information to release such information to the
Arkansas Veterinary Medical Examining Board.”
_______________________________________________
(Signature of Complainant)
(Date)
Subscribed and sworn before me this __________ day of ___________________, 20 _____.
______________________________________
(SEAL)
(Signature of Notary Public)
My Commission Expires: ____________________________________
Official Complaint Form
Page #3
LIST NAMES OF PERSONS WHO CAN CONFIRM ALL OR PART OF YOUR ENCLOSED STATEMENTS:
____________________________________________________________________________________________________________
NAME
ADDRESS
CITY
ZIP
PHONE
____________________________________________________________________________________________________________
NAME
ADDRESS
CITY
ZIP
PHONE
____________________________________________________________________________________________________________
NAME
ADDRESS
CITY
ZIP
PHONE
NOTICE: All complaints within the jurisdiction of the Board must be in writing, signed and dated by the complainant,
notarized and filed with the Executive Director of the Board. The Executive Director, upon receiving such complaint,
may proceed to investigate the complaint and take statements from any person thought to have knowledge of any
fact(s) pertaining thereto.
Page of 3