Department of Financial and Professional Regulation
Division of Professional Regulation State of Illinois
Complaint Intake Form

COMPLAINANT INFORMATION:

Please Note:

If more information is needed, you will be contacted via e-mail or telephone.
An acknowledgement letter will be sent to the email address you give here.

Your First Name:

Your Last Name:

Mailing Address 1:

Mailing Address 2:

City:

State:

Zip:

Your E-mail Address:

Day Telephone No: (as 999-999-9999)

Evening Telephone No: (as 999-999-9999)

YOUR COMPLAINT IS AGAINST (RESPONDENT) :

Professional's First Name:

Professional's Last Name or Name of Business*

Select the profession:Â Â	*
Street address (1st line):	*
Street address (2nd line):

City*		State:

Zip code:	*	Telephone No:(as 999-999-9999)	*

Date Event Occurred:(as 99/99/9999)	*	County Where Occurred:Â Â Â	*

BRIEFLY DESCRIBE YOUR COMPLAINT:

(NOTE: Limit 3,000 characters)
Do not enter URLs here - our form will not accept URLs.