By checking this box, I certify that:
I certify, under penalty of perjury, to the truth and accuracy of all statements and answers. All representations made in this Complaint Form are true and correct.
By checking this box, I further certify that I am signing this Complaint Form. I attest that the information provided herein is complete and true to the best of my knowledge and belief. I understand that any documentation attached to the complaint becomes the property of the Board and will not be returned to me. Further, I agree to voluntarily appear and give testimony regarding the information in this complaint if called upon by the West Virginia Medical Imaging & Radiation Therapy Technology Board of Examiners.