Customer Complaint Form

Company Letterhead

{{company_name}}

{{company_address}}

Phone: {{phone}}

Email: {{email}}

Website: {{website}}

Customer Complaint Form

Date of Complaint: {{date_of_complaint}}

Complaint Reference Number: {{complaint_reference_number}}

Customer Details

Full Name: {{customer_full_name}}

Contact Number: {{customer_contact_number}}

Email Address: {{customer_email_address}}

Physical Address: {{customer_physical_address}}

Preferred Method of Contact: {{preferred_contact_method}}

Details of the Incident/Complaint

Date of Incident: {{date_of_incident}}

Time of Incident: {{time_of_incident}}

Location of Incident (e.g., store name, department, online platform): {{location_of_incident}}

Nature of Complaint (e.g., product defect, poor service, billing error, staff conduct): {{nature_of_complaint}}

Please provide a detailed description of your complaint, including all relevant facts and events:

{{detailed_description_of_complaint}}

Relevant Parties Involved (if any)

Name(s) of staff member(s) involved (if known): {{staff_names_involved}}

Other parties involved: {{other_parties_involved}}

Supporting Documentation

Please list any supporting documents attached (e.g., receipts, photos, emails, contracts):

{{supporting_documents_list}}

These documents can be submitted via email to {{email}} or presented in person at {{company_address}}.

Desired Resolution

What outcome are you seeking to resolve this complaint? (e.g., refund, replacement, apology, corrective action, specific solution):

{{desired_resolution}}

Declaration and Consent

I, the undersigned, declare that the information provided in this complaint form is accurate and complete to the best of my knowledge. I understand that {{company_name}} will use this information to investigate my complaint.

I consent to {{company_name}} contacting me using the details provided above to discuss my complaint.

Signature of Customer: _______________________________

Date: {{signature_date}}

For Internal Use Only

Date Received: {{internal_date_received}}

Received By: {{internal_received_by}}

Action Taken/Investigator: {{internal_action_taken_investigator}}

Resolution Provided: {{internal_resolution_provided}}

Date of Resolution: {{internal_date_of_resolution}}

Signature Block

Customer Signature: ________________________

Date: {{date}}