LOUISIANA PROFESSIONAL ENGINEERING AND LAND SURVEYING BOARD

Page 1 of 3 REV. JUL 2017

AFFIDAVIT OF COMPLAINT AGAINST LICENSEE OR CERTIFICATE HOLDER

STATE OF ____________________

PARISH/ COUNTY OF _____________________

BEFORE ME, the undersigned Notary Public in and for the Parish/County of ____________________,

State of ______________________, came and appeared:

_____________________________________________

1. (“Affiant”), who, being duly sworn, stated that:

Affiant makes this Affidavit of his own personal knowledge.

2. Affiant’s home address, telephone number, and email address are:

3. Affiant’s firm name and business address, telephone number, fax number and email address are:

4. Affiant [ is is not] licensed as a [Professional Engineer, License #____________ /Professional LandSurveyor, License #____________ in the State of Louisiana.

Page 2 of 3 REV. JUL 2017

5. Affiant makes this Affidavit concerning certain statements, representations and/or activities of the followinglicensee/certificate holder for the purpose of making a complaint against said licensee/certificate holder withthe Louisiana Professional Engineering and Land Surveying Board (LAPELS) and as a potential basis forany action by LAPELS as it deems proper and appropriate:

Name:

Address:

Phone: Ext.

Email of Licensee/Certificate Holder:

6. The above named licensee/certificate holder made the following statements and/or representations and/orengaged in the following activities:

7. Affiant believes that the above described statements, representations and/or activities constitute a violationof the Louisiana Professional Engineering and Land Surveying Licensure Law, La. R.S. 37:681, et seq.and/or LAPELS Rules, LAC 46:LXI.101-3301.

8. As a result of the above described statements, representations and/or activities, Affiant has sustained thefollowing damages or losses:

Page 3 of 3 REV. JUL 2017

9. Affiant understands that based upon this Affidavit and/or other evidence developed, LAPELS may deem it necessary to conduct an investigation, which may result in further disciplinary proceedings or other legal action against the above named licensee/certificate holder. Affiant further understands that in such event, his/her testimony may be necessary and he/she agrees to be available as a witness to testify to the facts set forth in this Affidavit.

___________________________, ______________________,

this ________ day of _________________, 20______.

_____________________________________ (AFFIANT SIGNATURE)

SWORN TO AND SUBSCRIBED before me this ____ day of _____________, 20___.

_________________________________ NOTARY PUBLIC

My Commission Expires: (SEAL)

Note: This document is only a suggested form of affidavit of complaint against a professional engineer or

professional land surveyor. It should be varied by the affiant to accurately reflect the particular facts and circumstances. The only requirement of LAPELS is that the relevant facts are set forth concisely, completely and accurately, are based on the affiant’s personal knowledge and are sworn to before a Notary Public.