Please state clearly and specifically all allegations against person(s) named below. On a separate page list specific dates(s), full name(s )of all involved, and a statement describing each incident. Attach copies of any Documents you have concerning the allegation.
I acknowledge that the Arkansas Dietetics Licensing Board may provide a copy of this form to the above named person(s) against whom this allegation is made. I agree to testify in any hearing which may arise as a result of this allegation. The statements I have made are true and correct to the best of my knowledge and belief.
I hereby authorize all hospitals, institutions, dietitians, physicians, clinics, employers (past and present), laboratories, insurance companies, and/or all government agencies to release to the Arkansas Dietetics Licensing Board or its representatives, any and all information, records, files or documents in whatever form pertaining to information in their possession, or control. A copy of this release may be used by the Board in place
of the original.