MDA Vetboard

Are you registering an account to manage an existing license?

Are you registering to manage an existing Stable license?

Social Security Number

Password Confirmation

Your password must:

Not include your email address.
Include at least one number.
Include at least one special character. (such as ! # $ % & * + ~ @)
Include both lower and upper case characters (a-z) (A-Z).
Be at least 8 characters long.

Salutation

First Name

Last Name

Street

City

State

Zip

Home Phone

Cell Phone

Work Phone

Preferred Phone

Home Cell Work

Are you over 18?

Yes No

Is there a second complainant?

Salutation

First Name

Last Name

Street

City

State

Zip

Home Phone

Cell Phone

Work Phone

Preferred Phone

Home Cell Work

Is the second complainant over 18?

Yes No

Name of Licensed Facility

License Expiration Date

Describe the nature of the complaint. Include any pertinent dates. (25000 characters max)

Would you like to submit any physical documents related to this complaint?
Note: Physical documents must be submitted by mail to the Maryland Horse Industry Board office.

Please specify which records you would like to submit.

Bills

Medical Records

Laboratory Results

Radiographs

Please print your name clearly on each document and address to:

Maryland Horse Industry Board

50 Harry S Truman Parkway, Room 102

Annapolis, MD 21401

Have you contacted the facility in your complaint?

What was the result? (2500 characters max)

Have you contacted any other agency regarding this matter?

Name of Agency

Person Contacted

Is there a second agency that has been contacted?

Yes No

Name of Agency

Person Contacted

If this matter goes to a hearing, would you be willing to testify?
Note: Only the State Board or the subject of a complaint may request a hearing.

Do you know of witnesses with direct knowledge of the incident?

Which phone number is the best to reach this person?

What did the person witness? (2500 characters max)

Is there a second witness with direct knowledge of the incident?

Yes No

Salutation

First Name

Last Name

Relationship to you

Address

City

State

ZIP

Which phone number is the best to reach this person?

Home Cell Work

Home Phone

Work Phone

Cell Phone

What did the person witness? (2500 characters max)

Note: Your complaint, as part of the Board's Record, is subject to the Maryland Public Information Act. Ordinarily, it may not be inspected by the public. However, a copy ordinarily is furnished to the subject of the complaint, and that individual is asked to respond to it. Once a complaint is submitted to the Board, it may not be withdrawn unless the Board has no authority over the subject matter. If you have any questions, call the office at (410) 841-5798.

I understand and agree to this statement