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Consumer Information:
Required fields are marked with an *

Title * Mr.   Ms.   Mrs.
First Name  *
Last Name  *
Address  *
City  *
State/Province   *
Zip Code  * For U.S. zip codes, enter five digits only -- do not use Zip +4.
Country  *  United States   Canada  
Other: please enter country name  
Phone # (day)   Extension  
Phone # (eve.)  
Fax Number  
EMAIL   * 
 
Complaint to be Filed Against This Company:
Please provide as much information as possible about the company.
Company Name  *
Address  
City  
State/Province  
Zip Code  * For U.S. zip codes, enter five digits only -- do not use Zip +4.
Country  *
Phone Number   *
Fax Number  
WWW address  
 
Complaint Information

Please provide a brief, factual description of the problem you experienced. If you are notifying the BBB of an advertising claim that you believe is inaccurate or misleading, include the date and location of the advertisement.
 

In this section, not all fields may apply to your complaint. Please fill in the appropriate fields.

Date problem first occurred  
Date(s) you complained to Company  
To Whom  
Product or Service involved  
Brand Name or Manufacturer  
Model Name or Number  
Date Purchased  
Order, Contract, Acct. or Policy #  
Name of Salesperson  
Has this gone to court? *  Yes No
Have you already paid  
for the product or service?  		      Yes      No     Partial payment made
Purchase price  
Amount in Dispute  
Method of Payment  
Cash    Check    
Credit Card Money Order

Desired Settlement  
     Replacement Refund Other (Explain)