This form may be used to register a formal complaint against a particular company or organization. Kindly provide as thorough information as possible to assist us in responding to your complaint or to refer it to the relevant Agency. To learn how we use the information you provide, please read our Privacy Policy.

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This form will be sent to us directly at cacjam@infochan.com

 

 
First Name
Last Name
Age
Street Address
Town or City
Post Office
Parish
Country
E-Mail Address
Home Phone
 -
area code - phone number
Work Phone
 - -
area code - phone number - ext.
 
Describe Your Complaint
 
Subject of Your Complaint
Name of Company or Individual Against Which You Are Complaining
Branch
Street Address
Town or City
Parish
Country
Post Office
Company Web Site
Company E-Mail Address
Phone Number
 - -
area code - phone number - ext.
How Did You Make Initial contact With the Company?
Have you lodged a complaint with the company?
 Yes No
If yes, please indicate the date first lodged
(mm-dd-yyyy )
 
Product or Service Information
Date of Purchase, Service contracted or Entered Contractual Agreement?

(mm-dd-yyyy )
Indicate type of Purchase Agreement
Brand or Make of Product
How Much Did the Company Ask You To Pay?
 $
How Much Did You Actually Pay The Company?
 $
How Did You Pay the Company?
Warranty Period given
Account or Receipt number
 
Representative or Salesperson
 
First Name
Last Name
Explain Your Problem: Please limit your entry to 2,000 characters (about 30 lines)
   
Please indicate any other details specific to the product or service that have not been listed above.
   

 

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