Complaint Report Form printable pdf download

Complaint Report Form

CCSD: CCF-06-01

Last Revised: August, 2006

CUSTOMER COMPLAINT FORM

No:

_________

STATUS OF COMPLAINT: RESOLVED

UNRESOLVED

SECTION I – PERSONAL INFORMATION

DATE: ________________ TIME RECIEVED: _______________

Verbal

Written

NAME OF COMPLAINANT(S): ________________________________________________________________

ADDRESS: _________________________________________________________________________________

___________________________________________________________________________________________

TELEPHONE #: _________________________________________

SECTION II – NATURE OF COMPLAINT

TYPE OF COMPLAINT:

Licensing

Operations

Seizure

Other (state below)

PROBLEM DESCRIPTION:

TIME

(of incident): _____________________

LOCATION

(Where incident occurred): ___________________________________________________________________

DETAILS OF COMPLAINT:

___________________________________________________________________________________________

________________________________________________________________________________________

VEHICLE REGISTRATION #: _______________ MARKINGS ON VEHICLE__________________________

___________________________________________________________________________________________

DRIVER’S NAME:_____________________________________

BADGE #: ________________________

D/L #: ________________________________________________

NAME AND ADDRESS OF WITNESSES (Where necessary)

___________________________________________

____________________________________________

___________________________________________

Complaint Report Form