Request for Disciplinary Documents

If documents are not available for a discipline related matter through BreEZe Online Services, complete the form below and click Submit. The Board will respond to your request within ten business days.

Name:
Business Name:
Title:
Address:
City:
State:
Zip:
E-mail Address:
Phone Number:
How would you like to receive the documents? Email Mail
Would you like the documents certified? No Yes
RCP's Full Name:
License Number:
Date of Action (if known): (mm/dd/yyyy)
TYPE OF DOCUMENT(S) REQUESTED:

Reason for Request: