Unlicensed Activity Form - State Of Kansas Page 2
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23. DETAILS OF UNLICENSED ACTIVITY: As fully as possible, provide details concerning
the unlicensed activity, including any dates, locations, other specifics. Also include names,
addresses, and phone numbers of any other persons who may have knowledge of the
incident(s). Please specify your relationship to this person, e.g., client, employer, employee,
etc. Use extra pages if necessary. Attach copies of any documents, which support your
statement.
4. As part of an investigation into this matter, the Office of Attorney General may require the
person to respond to your allegations(s). While we cannot promise anonymity, is there a
reason why you would not want this person to be informed of your identity? Check one: ( )
yes ( ) no. If you checked “yes, please explain:
5. Will you willingly testify in a hearing before the Attorney General or her designee should
formal disciplinary proceedings be initiated? Check one: ( ) yes ( ) no. If you checked “no”,
please explain:
Signature:________________________________
Date:__________
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