| FORM NUMBER: |
| TIME: |
| The Director |
| Consumer Affairs Department |
C/o Ministry of Commerce, International Trade, Investment
Enterprise Development and Consumer Affairs |
| Micoud Street |
| Castries |
| Telephone Number |
| Fax Number |
| Email |
| Form Number: |
| Time: |
| SECTION 1 – INFORMATION ON THE CONSUMER |
| Christian Name: | Middle Name: |
| Surname: |
| Address: |
| Occupation: |
| Phone Number: Home: Work: Cell |
| Facsimile Number: |
| Sex: [ ] Male [ ] Female |
| Age Group: [ ] 18 – 30 [ ] 31– 45 [ ] 46 – 59 [ ] 60 and Over |
| Electronic Mail Address: |
| National Identification Number: |
| Social Security Number: |
| SECTION 2 – INFORMATION ON BUSINESS |
| Name: |
| Address: |
| Sector Code: |
| Phone Number: |
| Contact Number(s): |
| Business Code: |
| Facsimile Number: |
| Electronic Mail Address: |
| SECTION 3 – INFORMATION ON GOODS OR SERVICE |
| Goods or Service: |
| Model or Serial Number: |
| Category: |
| Date of Purchase: |
| Price or Value in Eastern Caribbean Dollars: |
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| Warranty or Guarantee: |
| Brand: |
| Brand Code: |
| Invoice/Receipt/Bill Number: |
| SECTION 4 – TECHNICAL INFORMATION ON PRODUCT |
| Manufacturing Date: |
| Standard: |
| Electrical Frequency Rating: |
| Voltage Required: |
| SECTION 5 – COMPLAINT IN A COURT OF LAW |
| State whether the complaint has been lodged in a Court or any intention to lodge in a Court of law [ ] YES [ ] NO |
| If yes, please state details: |
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| SECTION 6 – REDRESS SOUGHT |
| What form of redress would you consider a satisfactory solution? |
| Refund: [ ] Exchange: [ ] Repair: [ ] Credit Note: [ ] Other: [ ] |
| If other, please state: |
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| SECTION 7 – WILLINGNESS TO ATTEND AND TESTIFY AT PROCEEDINGS |
| I certify the above information to be truthful and accurate to the best of my knowledge and belief. I am willing to testify to the same at any proceedings directly related to this complaint if required to do so. |
| Signed: |
| Date: |
| Witnessed by: |
| SECTION 8 – THE COMPLAINT |
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| SECTION 9 – ADDITIONAL STATEMENT |
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| SECTION 10 - PROCESSING OF COMPLAINT FOR OFFICIAL USE ONLY |
| Director: |
| Authorized officer(s): |
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| Date: |
| Exhibits: |
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| Result: |
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| Signature: |
| Date: |