Department of Consumer Protection Complaint Form

INSTRUCTIONS: Complete the form with as much information as possible and click the "Submit Complaint" button at the bottom of this form. (* = required)
First Name:*
Middle Initial:
Last Name:*
Street Address:*
City:*
State:*	Postal Zip Code:*
Daytime Telephone:*	Please include the area code. If you do not have a phone, please indicate, "no phone"
Email Address:
Please complete the following information about the company you are submitting a complaint against:
Company Name:*
Street Address:
Additional Address:
City:*
State:*	Postal Zip Code:
Telephone Number:	Please include the area code
Internet Address:
Internet Email:
Product or Service in Dispute:*
Is the service or product for a Home Improvement?	Click in the box if your answer is "Yes."
Date of Transaction:*	Example: 1/2/00
Name of Company Representative
Title of Representative	Example: Sales Associate
Total cost of product or service:*	Example: $1,078.76
Amount you paid:	Example: $545.76
Date you contacted the company concerning your complaint?	Example: 1/2/00
Name of person contacted:
Describe the nature of your complaint:* (max. 3000 chars.)
What resolution are you seeking?*
I Hereby Certify that the information I have given is true and complete to the best of my knowledge. I understand that Westchester County Department of Consumer Protection complies with the Freedom of Information Law. I Authorize the Westchester County Department of Consumer Protection to act on my behalf in the mediation of this complaint.