COMPLAINT FROM -- Please print legibly
1. Name and home address of complainant:

Home phone: (       )                                         Best time to call:
Work address:

Work phone: (        )                                        Can we telephone you at work? Yes    No

COMPLAINT AGAINST
2. Name and address of business:

    Representative: Phone: (       )
3. Date of transaction:                                             Did you complain to company?    Yes      No

4. Have you hired an attorney to represent you in this matter?     Yes      No
    If yes, give name, address and telephone number of attorney:  

5. Have you filed your complaint with any court or administrative agency?   Yes      No
    If yes, give name and address of court or agency:

    
    When:                                                     Docket/File #

6. Describe the facts of your complaint in the order in which they happened
     (Use Additional Paper if  Necessary):

7. How do you wish this complaint to be resolved?

Please read the following before signing: Please attach to this form copies of any papers involved, contracts, bills received, receipts, cancelled checks, correspondence, etc. In order to resolve your complaint we may send a copy of this form to the person or firm you are complaining against. The information contained in this form is true, correct and complete to the best of my knowledge.

Date:                                           Signature: