Complaint Form
Field Description/Instructions
Complaint ID (Assigned by the company for tracking purposes)
Date of Complaint [MM/DD/YYYY]
Full Name of Complainant [First and Last Name]
Phone: [Phone Number]
Contact Information
Email: [Email Address]
☐ Customer Service ☐ Product/Service Quality ☐ Delivery Issue
Type of Complaint
☐ Billing ☐ Other: [Specify]
Detailed Description of [Please describe the issue in detail, including any relevant events,
Complaint conversations, and dates.]
Order Number: [Order #]
Transaction/Shipment
Tracking Number: [Tracking #]
Details
Shipment Date: [MM/DD/YYYY]
[What would you like as a resolution? Refund, Replacement,
Preferred Resolution
Repair, Other: Specify]
Additional Notes [Any other relevant information]
Signature of Complainant ________________________
Date ________________________
Loxdon Group Complaint Form
Customer and Employee Complaints