Better Business Bureau

Consumer Information (** Required Entry)

Title:  Mr.     Ms.     Mrs.

First Name:   **

Last Name:   **

Address:   **

City:   **

State/Province: Select State ------------ Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware 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 Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming   Select Province --------------- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan   **

Zip/Postal Code:   **

Phone # (day):   **

Phone # (eve):   **

Fax #:

EMail:   **

Firm Information
Please provide as much information as possible about the company.

Business or Charity Name:   **

Address:

City:

State/Province: Select State ------------ Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware 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 Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming   Select Province --------------- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan

Zip/Postal Code:   **

Phone Number:   **

Fax:

WWW Address:

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

Specifics:

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

Date Problem First Occurred:

Date You Complained to the 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)