Consumer Case No.

__________

COMPLAINT FORM
NAME OF COMPLAINANT: Age (Edad):
(Pangalan ng Nagrereklamo)
ADDRESS OF COMPLAINT: Gender:
(Tirahan)
Contact (Tel./Cel) No./
E-mail address:
NAME OF ESTABLISHMENT:
(Pangalan ng Tindahan)
ADDRESS OF STORE/
ESTABLISHMENT
Tel. No./Fax No:
Nature of Complaint:
(Uri ng Reklamo)
Name/Product/Brand Service:
(Produkto/Brand/Serbisyo)
NARRATION OF FACTS:
(Salaysay ng mga Pangyayari)

How would you like your complaint to be settled (Paano ninyo gusting maayos ang inyong reklamo?)
/____/ Refund (Isauli and pera) /___/ Repair (Kumpuni) /___Replace (Palit)
/____/ Proportionate Price Reduction (Kaukulang bawas sa Presyo)
Attached are xerox copies of the following supporting documents (Please check appropriate box):
/___/ Official Receipt /___/ Warranty card /____/ Service Report
I hereby certify that the foregoing statement are true and correct according to the best of my
knowledge and belief. (Pinatutunayan ko nang buong katotohanan ang mga nakasaad dito, batay sa
aking nababatid at paniwala.)

Received by (DTI staff)

________________________ _____________________
(Signature over Printed Name) (Signature of Complainant)
________________________
Date Received

RO3-AF-05
Revision 00
Effectivity Date : 19.10.09