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Ministry of Energy, Small Business and Entrepreneurship of Barbados

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OFFICE OF PUBLIC COUNSEL, COMPLAINT FORM

Date Of Complaint*:

Name and Address of Consumer

Name*:
Address*:
Telephone (H):
Telephone (W):
Telephone (C)*:
Additional Contact Numbers:
Email Address*:
Is Consumer expected to be out of the Island anytime soon? : YesNo

How Long*:

Name and Address of Supplier

Name*:
Address*:
Telephone (H):
Telephone (W):
Telephone (C)*:
Email Address*:
Is Supplier a register business?:YesNo
Is Supplier trading a business?:YesNo

DETAILS OF GOODS/SERVICES

Please select the detail: GoodsServices

Goods*:

Others*:

Identification of Goods:*:

Services*:

Others*:

Identification Of Services:*:

Date Of Purchase*:
Place Of Purchase*:
Price BDS $:
Receipt No:
Payment Terms: CashHire PurchaseCredit CardDebit Card

Contract No*:
Terms Of Contract: MonthlyWeekly
Details Of Complaint: Full Details To Be Given Separately, If Necessary.:*:
Have You Discussed Your Complaint With The Supplier?:YesNo
Dates:*:
Name:*:
Title:Owner/ManagerSupervisorEmployee
Responses:*:
Did The Consumer Request Supplier To Remedy The Breach?:YesNo
Redress Claimed:RectificationRefundCompensationRejectionReplacement
Signature With Date:*:

Summary of Complaint*:
Have you discussed your complaint with the Supplier? *:
Did you request supplier to remedy the breach?: YesNo

If YES, please state the remedy requested*:

Attachment

Signature

Signature of Consumer*:
Date*: