Consumer Complaints Form

1. Complainant Details

Given Name: (required)

Last Name: (required)

City/Town: (required)

Province: (required)

Email: (required)

Phone Number(s): (required)

Address:

2. Service Provider (Licensee) Details

Service Provider(Licensee): (required)

Customer Subscription Number: (required)

This is the number through which you have subscribed to the service

Service Type being complained of: (required)

Do you have Service Provider’s complaint reference number?: (required)

The reference number issued to you by the service provider after lodging your formal complaint

YesNo

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If Yes, Complaint Reference number:(required)

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If No, please provide date that complaint was made to the Service Provider:(required)

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Name of individual complaint reported to: (required)

Complaint Outcome (How was it resolved):

Brief Description of the complaint:

The desired remedy you are seeking:

Include details of how you would like NICTA to assist you