File a complaint Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastPhone *Email *Address *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeRelationship to Respondent *Name of Individual or Organization *FirstLastName of OrganizationCredential (if applicable)Certification Number (if known)Employer/Facility NameEmployer/Facility AddressType of Complaint *Ethics ViolationFraud/MisrepresentationCompetency IssueCriminal ActivityCEU FraudRenewal FraudOtherDate(s) of Incident(s) *Describe the Incident in Detail *Were there any witnesses? *YesNoIf Yes, List Witness Names + Contact Info defamatory Respondent JPG, Has this issue been reported to any other agency or employer? *YesNoIf Yes, provide detailsUpload Supporting Documents (PDF, JPG, DOC, etc.) Screenshots, Records, Emails, etc. Drag & Drop Files, Choose Files to Upload You can upload up to 40 files. I affirm the information provided is true to the best of my knowledge *YesI understand false claims may result in disciplinary action or legal liability *YesSignature * Clear Signature Date / Time *DateTimeNo refunds, chargebacks, or anonymous defamatory claims are accepted. NHCWA reserves the right to verify all information with employers, state boards, and law enforcement where applicable. *YesSubmit
