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Service Request Entry - Consumer Retail - General

Please complete as much information as possible and click the Review button.

( ** Mandatory fields have red labels. )


Location:  

Supporting Information

NOTE: PARTICIPANT NAME, ADDRESS & PHONE # REQUIRED!
Which item from the following list best describe the nature of your complaint?
If OTHER, please describe:
Which of the following types of documents do you have? (Select all that apply)
(Multiple answers allowed)
Please Retain All Documents - BACP will follow-up with you.
Type of merchandise and/or service involved (including brand) ?
Approximately how much were you charged for the merchandise or service?
When did the incident occur?
What time of day did the incident occur?
Input cell # to opt-in for text updates. If opted-in, add cell # to caller info.


Caller / Contact Information
First Name Last Name
Street Address
Address 2
City
E-Mail Address
Contact Type Contact Number   Extension/Comments