Customer Complaint Form

Customer Details

Surname
Given Name
Company
Street Address
Suburb
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