I wish to complain against the facility or agency named below.  I am submitting this information so that it may be determined if licensing action against this facility or agency should be considered.

Your
Name:

Will you testify in an administrative hearing?
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By entering my name in the space provided below and transmitting this form electronically, I state that I am the person named on this form. I certify by my signature that the information provided by me is complete and accurate.

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