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Complaint Form

Details of Complainant

First Name:  *
Last Name:  *
Address:  *
ZIP Code:  *
Prefecture:  *
Telephone:  *
FAX:
Email:
Fields with * are mandatory!

Description of Event

Date of Event:
Description*

Implicated Product

Type of Product:
Trade Name:
Producer's - packager's details:
Packaging (pre-packed - bulk food - packaged at point of sale):

Labeling Details:

Date of Production/Expiration:
Lot No:

Details of company where the event took place

Title:
Type of company:
Address:  *
Number:  *
District:  *
Postal Code:  *
Telephone/Fax:
Manager's Name: