Store Complaint Form

Date submitted:

Full name:

Email:

Telephone:

Name of store:

Street address of store:

City/Town/Village where store is Located:

Zip Code:

Date item purchased/Date at store:

Describe item purchased (name of item and weight):

Do you have a receipt: Yes
No

Did you speak to the clerk or manager at the store: Yes
No

Describe complaint:

Maximum number of characters: 2,000

Retype the characters from the picture in the space provided: (Required)