Complaint Form

Your Contact Information

First Name:
Last Name:
Address:
City:
Province:
Postal Code:
Daytime Phone:
ext:
Evening Phone:
Fax:
Email Address:

Company You Are Complaining About

Company Name:
Business Address:
City:
Province:
Postal Code:
Phone:
Website:
Contact Email:

Complaint Information

Please provide a brief, factual description of the problem you experienced. If you are notifying IntegrityLink of an advertising claim that you believe is inaccurate or misleading, include the date and location of the advertisement.

Additional Complaint Information

In this section, not all fields may apply to your complaint. Please fill in the appropriate fields.

Date Problem First Occured:
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Date You Complained To Company:
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Person You Complained To:
Product or Service Involved:
Brand Name Or Manufacturer:
Model Name or Number:
Date Purchased:
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Order, Contract, Acct or Policy #:
Name Of Salesperson:
Have you paid for the product/service?
Purchase Price:
Amount In Dispute:
Method Of Payment:
Desired Settlement: