Consumer Complaint Form

Consumer Complaint Form

Competition and Consumer Affairs Commission (CCAC) Consumer Complaint Form Pursuant to Section 9 of the Consumer Affairs Act 2011
Consumer Information
Date of Complaint

DayMonthYear
Date
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

RegionRegion

Postal / Zip Code
National ID*
Age*
Gender*
Home Phone
Please enter a valid phone number.Format: (592) 000-0000.
Mobile Phone*
Please enter a valid phone number.Format: (592) 000-0000.
Work Phone
Please enter a valid phone number.Format: (592) 000-0000.
Supplier Information
Business Name*
Senior Official Name
Business Address*

Street Address

Street Address Line 2

Region/ProvinceState / Province

Postal / Zip Code
Business Phone
Please enter a valid phone number.Format: (592) 000-0000.
yesNo
If yes, Date of complaint

MonthDayYear
Product of Service Information

Fill applicable areas only
Date of Purchase/Service*

MonthDayYear
Product or Service Name*
Brand/Type
Value of Item/Service*
CashLayawayHire purchaseOther
If Other, Please state
ConsumerSupplierNAOther
If Other, please state
Model Number
Serial Number
Manufacturer's Name
Manufacturer's Address

Street Address

Street Address Line 2

City/RegionState / Province

Postal / Zip Code
Electrical frequency rating of the product (Hz)
Business Compliance
YesNo
If yes, what is the duration of warranty?
YesNo
If No, please state why
HazardsCare7 days return policy for productsProper UsConditions for redress
Please provide a summary of your complaint*
Complainant's Proposed Resolution*
Please upload any supporting documents.

Cancelof
Declaration
yesno
I First Name Last Name hereby certify that the above information provided is true and correct to the best of my knowledge and belief. I Certify*
Should be Empty:

Consumer Complaint Form

Consumer Information

Supplier Information

Product of Service Information

Business Compliance

Declaration