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Store Complaint Form

Please note your Name and Telephone number are confidential.

Date submitted:      

Full name:



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:

Did you speak to the clerk or manager at the store:

Describe complaint:

Maximum number of characters: 2,000

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