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RO3 AF 05 Complaint Form
RO3 AF 05 Complaint Form
RO3 AF 05 Complaint Form
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COMPLAINT FORM
NAME OF COMPLAINANT: RUTH PAMINTUAN CARREON AGE (Edad)
(Pangalan ng Nagrereklamo) 53
ADDRESS OF COMPLAINT: 30-6 PARIS, DON BONIFACIO, BALIBAGO, Gender:
(Tirahan) ANGELES CITY F
Contact (Tel./Cel) No./ 09158823093
E-mail address:
NAME OF ESTABLISHMENT: LAUS AUTOGROUP (MITSUBISHI PAMPANGA)
(Pangalan ng Tindahan)
ADDRESS OF STORE/ JOSE ABAD SANTOS AVENUE, CITY OF SAN
ESTABLISHMENT FERNANDO, PAMPANGA
Tel. No./Fax No: (045) 963 1111
Nature of Complaint: VIOLATION OF THE CONSUMER ACT OF THE
(Uri ng Reklamo) PHILIPPINES (R.A. 7394)
Name/Product/Brand Service: MITSUBISHI MOTORS PHILIPPINES, INC.
(Produkto/Brand/Serbisyo)
NARRATION OF FACTS: SEE ATTACHED VERIFIED COMPLAINT LETTER
(Salaysay ng mga Pangyayari)
How would you like your complaint to be settled (Paano ninyo gusting maayos ang inyong reklamo?)
/____/ Refund (Isauli and pera) /___/ Repair (Kumpuni) /___Replace (Palit)
/____/ Proportionate Price Reduction (Kaukulang bawas sa Presyo)
Attached are xerox copies of the following supporting documents (Please check appropriate box):
/___/ Official Receipt /___/ Warranty card /____/ Service Report
I hereby certify that the foregoing statement are true and correct according to the best of my
knowledge and belief. (Pinatutunayan ko nang buong katotohanan ang mga nakasaad dito, batay sa
aking nababatid at paniwala.)
________________________ _____________________
(Signature over Printed Name) (Signature of Complainant)
________________________
Date Received
RO3-AF-05
Revision 00
Effectivity Date : 19.10.09