In terms of Regulation 4 of the Regulations Regarding Consumer Complaints, consumer Complaints must be submitted on this form, after the Respondent has been given fourteen (14) days to first resolve the matter.

Was this complaint first submitted to the Respondent?
YesNo

If yes, what date was it submitted to the Respondent?

If no, first submit a complaint to the Respondent and allow the Respondent fourteen (14) days to resolve the matter, alternatively provide a clear and concise statement of the reason why the complaint was not first submitted to the Respondent.

A. COMPLAINANT

Complainant

Physical Address

Postal Address

Telephone number(s)

Facsimile number(s)

Electronic mail address(es)

B. CONTACT PERSON (IF DIFFERENT FROM COMPLAINANT)

Contact Person

Physical Address

Postal Address

Telephone number(s)

Facsimile number(s)

Electronic mail address(es)

C. RESPONDENT

Contact Person

D. COMPLAINT

Provide an accurate and concise statement of the facts illustrating the Complaint and demonstrating that the Respondent acted wrongly.

E. RELIEF SOUGHT

Provide a clear and concise statement of the specific relief or remedy sought.

F. ANY OTHER INFORMATION

Provide any other relevant information

Attach file

The applicant warrants that the information provided herein is true and correct.
Yes