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Your Information
Full Name
Gender
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Female
Preferred Contact Number
Home Phone
Work Phone
Cell Phone
Email Address
Have you attempted to resolve this issue with the company?
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Yes
No
Company Information
Name of Company
Name of Manager / Owner
Contact Number
Complaint Information
Is the complaint about a car, bike or boat?
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No
Product
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No
Name of Product (please include make, model and number)
Date Purchased
Service
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No
Type of Service
Nature of Complaint
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Advertising
Billing
Contract
Credit/refund
Customer Service
Delivery
Lost/Damaged Goods
Product Quality
Refund or Exchange
Repairs
Selling
Service
Warranty
Briefly describe the details of your complaint
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Car, Bike or Boat
Vehicle Model
Vehicle Make
Date of Purchase
License Number
Date problem started
How many days has the vehicle been out of service for repair?
Nature of Complaint
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Advertising
Billing
Contract
Credit/refund
Customer Service
Delivery
Lost/Damaged Goods
Product Quality
Refund or Exchange
Repairs
Selling
Service
Warranty
Briefly describe the nature of your complaint
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Resolution
Do you have any documents supporting your complaint?
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Yes
No
If yes, what are they?
Receipts
service records
letters
email
statements
quotes
invoices
professional opinion
What would satisfy your complaint?
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Refund
Reimbursement
Replacement
Repairs
Apology
