Post Office Complaint Form (Page 2 of 2) in pdf

TO: THE ETHICS COMMITTEE

NORTH CAROLINA BOARD OF ATHLETIC TRAINER EXAMINERS

P.O. Box 10769

Raleigh, NC 27605

I, the undersigned, hereby file a complaint against

_________________________________________________

(full name)

__________________________________________

(street address) (city, state, zip)

I agree to cooperate by furnishing to the representatives of the North Carolina

Board of Athletic Trainer examiners all pertinent information and records in my

possession concerning the alleged misconduct of said professional.

I further agree that if a hearing or inquiry is ordered concerning the alleged

misconduct of said professional, then I will furnish evidence concerning the facts by

submitting to deposition or personal attendance at that hearing or inquiry.

I hereby indicate that this information is provided and transmitted by me to the

North Carolina Board of Athletic Trainer Examiners for the purpose of

investigating the alleged misconduct of the above named professional.

I understand that I may reveal this information to privately-retained attorney to

pursue remedies on my behalf.

I also understand that the North Carolina Board of Athletic Trainer Examiners may

reveal this information to the accused professional for his or her response to a

formal inquiry and to others pursuant only to the Rules of the North Carolina

Board of Athletic Trainer Examiners. Additionally, this information may become

public only upon the direction of the North Carolina Board of Athletic Trainer

Examiners, pursuant to its policies and procedures.

This the ______ day of _______________________, 20______.

________________________________

Signature of Complainant

________________________________

Street Address

________________________________

City, State, and Zip

________________________________

Telephone (Home and Office)

Post Office Complaint Form Page 2