Illinois Department of Financial & Professional Regulation Illinois Department of Financial & Professional Regulation
 
Bryan A. Schneider, Acting Secretary  
Bruce Rauner, Governor
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Professional Regulation Complaint Intake Form
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 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:   *
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 :


(NOTE: Limit 3,000 characters)
 

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