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Customer Complaint Form

Customer Details

Given Name  
Street Address  
Postcode and State  
Telephone Number  
Fax Number  
Mobile Number  
E-mail Address  

Details of Goods or Services Supplied to the Customer

Date of Purchase or Service
Description of Goods or Service including Make, Model, Type of Service

Details of what the Customer Complaint is


Office Use Only

Complaint Received By Date
Action taken or Required
Date Action Completed Signature