Defective Product

Sample Complaint Form

1. Name of Complainant: _____________________________________________________________________

2. Address: ________________________________________________________________________________

3. Phone Number: ___________________________________________________________________________

4. Name of Product: _________________________________________________________________________

5. Model and Serial Number (if applicable) _______________________________________________________

6.  Nature of Complaint (Be specific. Note the date purchased, where purchased, specific problem encountered with the product.)

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6. Witnesses to the Complaint (if any) ______________________________________________________________________________________

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Signature of the Complainant (or person filling out form):

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Date:____________________