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Fill and Sign the Inland Respite Timesheet 2020 Form

Fill and Sign the Inland Respite Timesheet 2020 Form

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ALABAMA STATE BOARD OF RESPIRATORY THERAPY P.O. Box 241386, Montgomery, AL 36124-1386 Phone: 334-396- 2332 Fax: 334-396-2384 Web Site: www.asbrt.alabama.gov COMPLAINT FORM Your Name: ______________________________________________________________________________ (last name) (first name) (Middle) Your Address: _____________________________________________________________________________ (Street) _____________________________________________________________________________________________ (City) (County) (State) (Zip) Day Phone: _________________________________ Evening Phone:___________________________________ ****************************************************************************************** Whom do you wish to complain about: Name: __________________________________________________________________________________ Organization: _____________________________________________________________________________ Address: _________________________________________________________________________________ (Street) _________________________________________________________________________________________ (City) (State) (zip) (Phone) To whom did it happen: ( ) you ( ) Member of your family ( ) Other Please Identify:________________________________________________________________________________________ Did anyone witness what happened? ( ) yes ( ) no Who (give name): _____________________________________________________________________________________ Could this witness confirm your story? ( ) yes ( ) no Would witness be willing to testify? ( ) yes ( ) no Would you be willing to testify if necessary? ( ) yes ( ) no Do you have any bills, forms, or other written evidence that concern this complaint? ( ) yes ( ) no Please send copies of related papers along with this form. DO NOT send originals. **************************************************************************************************** The information I have given in this complaint is true, correct, and accurate to the best of my knowledge. Signature__________________________________________ Date _________________________ Please give details of complaint on back of this form. Return Completed form to: The Alabama State Board of Respiratory Therapy P.O. Box 241386, Montgomery, AL 36124-1386 Phone: 334-396-2332, FAX 334-396-2384 5/16/05

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