Complaint Review Form
A. Detailed Complainant
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1. Title (Mr./Mrs./Ms./Other
Surname
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First Names
2 (a). Account Name (From Bill)
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2 (b). Account Number (From Bill)
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3. Services Address
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4. Contact Details
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Mailing Address
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Telephone Number
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Fax Number
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Email
B. Details of Complaint
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1.Type of Service (Fixed/Mobile/Internet/VoIP/Subscription TV/other)
2. Contact Details of the Service Provider
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Full Name
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Mailing Address
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Telephone Number:
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Fax Number:
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E-Mail:
3. Nature of Complaint and indicate remedy sought (service interruption/quality ofservice/billing dispute/service provision delay/poor Customer Service/ Access to Customer Service/Other)
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4. Date of first reporting to the Service Provider
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5. Reference number (obtained from the Service Provider)
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6. Details of the documents relevant to the complaint (attach photocopies of bills, service level agreement, contract etc....)
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7. Present status in resolving the problem by the Service Provider (attached photocopies of letters or e-mails sent to the Service Provider to show that all means to resolve the complaint has been exhausted)
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Signature
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Date
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Month
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Day
Year
Date
Submit
Should be Empty: