Consumer Complaint Form

This form must ONLY be completed if your service provider has not been able to solve the problem(s) that you reported to them

PART 1: PARTICULARS OF THE PERSON FILLING OUT THIS COMPLAINT FORM

Click here for a blank PDF version of this form

Title:

First Name:

Last Name:

Street 1:

Street 2:

City/Town

Contact No:

Fax:

Email:

PART 2: PARTICULARS OF REGISTERED CUSTOMER (PERSON AFFECTED BY THE PROBLEM)

Title:

First Name:

Last Name:

Address

Street 1:

Street 2:

City/Town:

Account # or phone number affected if applicable:

PART 3: PARTICULARS OF COMPLAINT

Service Provider:

Date Complaint was lodged with service provider:

Type of Service:

Nature of Complaint:

Complaint Details: (If necessary you may attach further details of your complaint on a separate document)

Signature

Date