Customer Complaint Form

Customer: Name/Address/City/State/Zip
Identify the person who had the problem
Name:		Phone:		Product/Quantity:
Address:		Email:		Item#:
City:		Lot#:
State:
Zip:

Operator: Name/Address/City/State/Zip
Identify WHERE the product was served or purchased (school, c-store, other, etc.)
Name:		Phone:		Contact:
Address:		Email:		Title:
City:		Distributor:
State:
Zip:

Distributor: Name/Address/City/State/Zip
Identify who delivered the product to the Operator/End User?
Name:		Item#:		Quantity:
Address:		Lot Number:		Invoice#:
City:		PO Number:		Carrier:
State:		Contact/Title:
Zip:

Has a sample been obtained?

Description of problem:

Comments:

Entered By:

Date: