Ethics Complaint Form | Maryland Addiction and Behavioral-health Professionals Certification Board

Subject's Information

First

Middle

Last

Birthdate

Credential Held by Professional

Certification Number

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Home Phone

Cell Phone

Employer Information

Employer Name

Work Phone

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Complainant's Information

First

Middle

Last

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email

Phone

Complainant's Business Name

Certification Number

Relation to Subject

Incident Information

Incident Date

Please describe in as specific detail as possible the facts, circumstances, situations and allegations concerning the complaint.