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Fri 12 March 2010
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  • Compliment
  •  
  • Complaint

SUPPLIER'S NAME

  Co. who responds

  Company who doesn't respond

SUPPLIER'S COUNTRY  
BRANCH/AREA

e.g. suburb, shopping centre, branch.

SUPPLIER'S INDUSTRY

If the supplier does NOT appear
in the pop up list.

PERSON RESPONSIBLE  
PROBLEM  
OTHER

e.g. Programme content, incorrect diagnosis etc.

HEADLINE

(50)

WHAT HAPPENED? ONE report per Supplier will be accepted in a 24 hour period.

 characters left
DATE & TIME OF INCIDENT   : :
YOUR ACC/POLICY NO.

NOT displayed on the website.
For reports re Accounts, Subscriptions etc.

CELL PHONE NUMBER

NOT displayed on the website.
For reports to Cell Phone Companies.

I understand that my details (name, contact number and email address) will be exposed ONLY to the supplier concerned, and ONLY if the supplier is a subscriber (Company Who Responds).