|Thank you for taking the time to complete this online form. Be sure to complete all of the information, which will help us to investigate your concerns.
Name of Complainant:
Please send me a copy of the results.
Phone Number: Date of Complaint:
Firm's Name: Address:
(Examples: fuel pump, scale, scanner, package commodity)
Location of Device:
(Examples: pump 3, premium gas, 87 octane, scale in aisle 7, back counter)
Reason For Investigation: