Date:
Customer:
Address:
City, State, Zip:
Phone: 

Merchandise Problems: 

Delivery Problems: 


[   ] Order Not Filled                  [   ] Bad Address 
[   ] Defective Merchandise     [   ] Customer Not In
[   ] Repair Problem                  [   ] Delayed/Lost In Transit 
[   ] Wrong Merchandise Sold  [   ] Damaged In Transit
[   ] Amount Charged In Error   [   ] Mdse. Missing In Pkg.
[   ] Credit/Refund Not Issued  [   ] Other:

Other remarks:  
 
Disposition:


By: ________________________________________ 
(name of Customer Srevice Representative)