COMPLAINANT FORM
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
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Indiana
Iowa
Kansas
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Type of Complaint
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Motor Fuel
Package Weight
Price Verification
Product Labeling
Scale
Taxi Meter
Vehicle Tank Meter
Firewood
Type of Complaint
Motor Fuel
Package Weight
Price Verification
Product Labeling
Scale
Taxi Meter
Vehicle Tank Meter
Firewood
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Motor Fuel Complaint
Date of Occurrence:
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Month
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Day
Year
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Time:
Hour : Minutes Minutes
AM
PM
AM/PM Option
Do you have the receipt?
Please Select
YES
NO
Do you have the receipt?
Yes
No
Pump #:
Grade:
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87 E10 Regular
87 Conventional Regular
89 E10 Plus
89 Conventional Plus
91 Conventional Super
93 E10 Super
93 Conventional Super
E15
E85
Diesel
Other (Describe in "Nature of the Complaint" box)
Nature of the Complaint:
Package Weight Complaint
Date of Occurrence:
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Month
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Day
Year
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Time:
Hour : Minutes Minutes
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PM
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Do you have the receipt?
Yes
No
Do you have the receipt?
Please Select
YES
NO
Product Name:
Brand Name:
Label Weight and/or Volume:
Nature of the Complaint:
Price Verification Complaint
Date of Occurrence:
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Year
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Time:
Hour : Minutes Minutes
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PM
AM/PM Option
Do you have the receipt?
Yes
No
Do you have the receipt?
Please Select
YES
NO
Product Name:
Brand Name:
Product Size:
UPC Code:
Price Advertised:
Price Charged:
Nature of the Complaint:
Product Labeling Complaint
Date of Occurrence:
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Year
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Time:
Hour : Minutes Minutes
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PM
AM/PM Option
Do you have the receipt?
Yes
No
Do you have the receipt?
Please Select
YES
NO
Product Name:
Brand Name:
Product Size:
Nature of the Complaint:
Scale Complaint
Date of Occurrence:
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Time:
Hour : Minutes Minutes
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PM
AM/PM Option
Do you have the receipt?
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YES
NO
Do you have the receipt?
Yes
No
Nature of the Complaint:
Taxi Meter Complaint
Date of Occurrence:
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Month
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Year
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Time:
Hour : Minutes Minutes
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PM
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Do you have the receipt?
Yes
No
Do you have the receipt?
Please Select
YES
NO
Pickup Location:
Pickup Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Drop Location:
Drop Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cab Number:
Nature of the Complaint:
Vehicle Tank Meter Complaint
Date of Occurrence:
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Month
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Day
Year
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Time:
Hour : Minutes Minutes
AM
PM
AM/PM Option
Do you have the receipt?
Yes
No
Do you have the receipt?
Please Select
YES
NO
Truck Number:
Nature of the Complaint:
Firewood Complaint
Date of Occurrence:
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Month
/
Day
Year
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Time:
Hour : Minutes Minutes
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PM
AM/PM Option
Do you have the receipt?
Yes
No
Do you have the receipt?
Please Select
YES
NO
Nature of the Complaint:
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