1. Title and Name

please select one of the following
Mr
Ms
Mrs
Miss
Other (please specify below)

First Name

Last Name

2. Your Address

Address 1

Address 2

Address 3

Town

Postcode

County

3. Contact Details

Email

Daytime Phone Number (including dialling code)

4. Your Complaint:

Please explain the nature of your complaint:

5. What action would you like us to take?

Please select
Apologise
Reconsider a decision
Change the way something is done
Other (please describe below)

6. Have you already contacted us about this matter?

please select one of the following
YES (see below)
NO (go to question 7)

a) When did you contact us?

b) Who did you contact? (if known)

c) Have you received a reply?
YES
NO

7. Accompanying Documents

If you are sending us any original documents relating to your complaint and would like us to return them to you, please tick the box:

8. Is someone acting on your behalf

If you are asking someone to act on your behalf please tick this box to give us permission to dicuss your compliant with them:

Please complete their contact details below.

Nominee's First Name

Nominee's Last Name

Nominee's Address

Address 1

Address 2

Address 3

Town

Postcode

County

Daytime Phone Number (including dialling code)

Send a copy of this message to my e-mail address