Alaska Division of Occupational Licensing

State of Alaska

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> Complaint Form

STATE OF ALASKA
DEPARTMENT OF COMMERCE COMMUNITY AND ECONOMIC DEVELOPMENT
DIVISION OF OCCUPATIONAL LICENSING
550 W. 7TH AVE, SUITE 1500
ANCHORAGE, AK 99501
(907) 269-8160
E-MAIL: INVESTIGATIONS@COMMERCE.STATE.AK.US
WEB SITE: COMMERCE.STATE.AK.US/OCC

COMPLAINT FORM

All fields marked with an (*) are required fields.

COMPLAINT REGISTERED AGAINST:

*First Name:			*Last Name:
*Profession:
Address:
City:		State:		Zip Code:
Work Phone:	(9999999999)

PERSON REGISTERING COMPLAINT:

*First Name:			*Last Name:
*E-mail Address:			Date of Birth:	(MM/DD/YYYY)
Address:
City:		State:		Zip Code:
Home Phone:	(9999999999)	Work Phone:		(9999999999)

DETAILS OF COMPLAINT:

Please briefly describe your complaint i.e. dates, witnesses (and contact information)

You must check yes or no to the following questions. Incomplete forms will not be accepted.

1. YES NO I hereby attest that I am the complainant registering a complaint against the above-named individual and that the information I have provided is true and correct to the best of my knowledge.

2. YES NO If a different agency or society would more appropriately address my complaint, I authorize the Division of Occupational Licensing to forward my complaint to that agency or society.

Be forewarned that when you submit confidential information via the Internet, there is the possibility that persons who were not intended to receive, or have access to your personal information could intercept your transmittal.

AS 11.56.210(a)(2) of the Alaska Statutes makes it a class A misdemeanor offense for a person to intentionally issue a false written or recorded statement, which is punishable by imprisonment for not more than one (1) year, a $5,000 fine, or both.

In order to process the complaint, the Investigation Unit will follow-up with you to obtain a signed complaint, a release of information and detailed information.


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