Complainant Information
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Name
First Name
Last Name
Phone
Format (000) 000-0000
E-mail
example@example.com
Mailing Address
Street Address
Street Address Line 2
City
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Alabama
Alaska
Arizona
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District of Columbia
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State
Zip Code
Complaint Against
Company Name
*
Location Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Type of Complaint
*
Please Select
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:
-
Month
-
Day
Year
MM-DD-YYYY
Time:
Hour : Minutes Minutes
AM
PM
AM/PM Option
Do you have the receipt?
Please Select
YES
NO
Pump #:
Grade:
Please Select
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:
-
Month
-
Day
Year
MM-DD-YYYY
Time:
Hour : Minutes Minutes
AM
PM
AM/PM Option
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:
-
Month
-
Day
Year
MM-DD-YYYY
Time:
Hour : Minutes Minutes
AM
PM
AM/PM Option
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:
-
Month
-
Day
Year
MM-DD-YYYY
Time:
Hour : Minutes Minutes
AM
PM
AM/PM Option
Do you have the receipt?
Please Select
YES
NO
Product Name:
Brand Name:
Product Size:
Nature of the Complaint:
Scale Complaint
Date of Occurrence:
-
Month
-
Day
Year
MM-DD-YYYY
Time:
Hour : Minutes Minutes
AM
PM
AM/PM Option
Do you have the receipt?
Please Select
YES
NO
Nature of the Complaint:
Taxi Meter Complaint
Date of Occurrence:
-
Month
-
Day
Year
MM-DD-YYYY
Time:
Hour : Minutes Minutes
AM
PM
AM/PM Option
Do you have the receipt?
Please Select
YES
NO
Pickup Location:
Drop Location:
Cab Number:
Nature of the Complaint:
Vehicle Tank Meter Complaint
Date of Occurrence:
-
Month
-
Day
Year
MM-DD-YYYY
Time:
Hour : Minutes Minutes
AM
PM
AM/PM Option
Do you have the receipt?
Please Select
YES
NO
Truck Number:
Nature of the Complaint:
Firewood Complaint
Date of Occurrence:
-
Month
-
Day
Year
MM-DD-YYYY
Time:
Hour : Minutes Minutes
AM
PM
AM/PM Option
Do you have the receipt?
Please Select
YES
NO
Nature of the Complaint:
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