Customer Complaint Form

CUSTOMER COMPLAINT FORM

All sections as marked * are to be completed prior to lodging form at Council

All personal details remain CONFIDENTIAL

Complaints will be acknowledged within 5 working day

of receipt and a resolution within 15 days

*Name of person making Complaint

*Residential Address

*Postal Address

*Contact Number/s Email

COMPLAINT DETAILS

Date of Incident (if relevant) Time

Location of Incident

Who/What is the subject of your Complaint

Summary of Complaint/Issue

WITNESS DETAILS (if applicable)

Name

Address Daytime Contact Number

COMPLAINT OUTCOME:

As a result of making this complaint, is there any outcome you would like? Yes ◻ No ◻ If yes, please provide details

Upon signing this form I agree that should legal proceedings be required I will

APPEAR IN COURT AS A WITNESS TO GIVE EVIDENCE TO THE TRUTH OF THIS COMPLAINT

*Complainants name

(signature) (date)

Lodge written Complaint:

• By posting to Port Augusta City Council, PO Box 1704, PORT AUGUSTA SA 5700

• Faxing to (08) 0841 0357

• Emailing to admin@portaugusta.sa.gov.au

F10/2945 - AR11/5432

COUNCIL USE ONLY

INVESTIGATION DETAILS

Name of Person investigating incident

Title					Date of Investigation		/	/
Customer complaint acknowledged	Date:	/	/	(within 5 days of receipt)
Investigation Details

(If no action is to be taken, please explain why)

ACTIONS ARISING FROM INVESTIGATION Date to be completed

Immediate

Further recommendations

INVESTIGATION OFFICER

Signature					Date
Complainant Advised  Yes ◻  No ◻	Record No  AR	/	Date

Download Word Document In English. (Rs.30/-)

Customer Complaint Form (English)

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