Jay Stewart, Acting Director Division of Professional Regulation  
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Pat Quinn, Governor

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Springfield Office:
320 West Washington St
Springfield, IL 62786   directions

Chicago Office:
James R. Thompson Ctr
100 W. Randolph St
Suite 9-300
Chicago, IL 60601   directions
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 acknowledgment letter will be sent to the 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 Phone No:(as 999-999-9999)
YOUR COMPLAINT IS AGAINST (RESPONDENT) :
 
Professional's
first name:  		 Middle Initial Professional's Last Name
or Name of Business*
           
Select the profession:   *
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:    *
   


Briefly describe your complaint:
(Limit 3,000 characters)
 



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