Register February 2013 No. 686
APPENDIX I
State of Wisconsin
Department of Safety and Professional Services
Division of Enforcement
CITATION
_____________________________________________________________
Name of Credential Holder/Establishment
_____________________________________________________________
Street City Zip
_____________________________________________________________
Establishment/Owner License #
An investigation/inspection has disclosed the following violations, which must be corrected. Pursuant to s.
454.15 (3), Wis. Stats., the licensing authority is authorized to impose a forfeiture in lieu of or in addition to other disciplinary action against your license.
_____________________________________________
Day of Week Date Time
On the above stated time, date and location, the above-identified credential holder (describe violation - state facts.)
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
in violation of Section(s) _______________ of the Wis. Stats. Wis. Adm. Code.
__________________________________________________________________
Signature of Investigative Staff Title
PLEASE TAKE NOTICE that the credential holder may deposit a FORFEITURE and costs in the amount of ________________ by mailing a check or money order by no later than twenty (20) days from the date of this citation in the amount of the forfeiture, together with the signed white copy of this form to: the Department of Safety and Professional Services Division of Enforcement, 1400 East Washington Avenue, PO Box 8935, Madison, WI 53708. Payment shall be treated as a plea of no contest to the violation(s) cited above and submission to an order of forfeiture plus costs, not to exceed the amount of the deposit.
State of Wisconsin
Department of Safety and Professional Services
Division of Enforcement
CITATION
_______________________________________________________________________
Signature of Licensee/Establishment Owner Date
FURTHER NOTICE that within twenty (20) days of the date of service of this citation, the licensee may enter a plea contesting the violation(s) cited and request a hearing on the alleged violation(s). Submission of a plea contesting violations and requesting a hearing shall be in writing and submitted to the Department of Safety and Professional Services Division of Enforcement, 1400 East Washington Avenue, PO Box 8935, Madison, WI 53708.
If the credential holder does not make a deposit or otherwise respond to the citation in a timely fashion, the disciplinary authority may without further proceedings issue an order of default against the credential holder. A default order issued under this section may impose forfeiture and costs, not to exceed the amount identified in the citation. Violation of an order issued pursuant to this section may result in a refusal to renew credentialing or additional disciplinary action.
If the credential holder requests a hearing but fails to appear at the hearing at the time fixed therefor, the credential holder is in default and the disciplinary authority may make findings and enter an order on the basis of the citation.
