Department of Science and Technology

COMPLAINT (REKLAMO) FORM

Date (Petsa): ______________________

Name of Complainant: ______________________________ Tel/Fax/CP No. ___________________

(Pangalan ng Nagrereklamo)

Name of Office: ____________________________________ Email Address: ___________________

(Pangalan ng Tanggapan)

Residence Address: _________________________________________________________________

(Tirahan)

Name of Person Being Complained of: ___________________________________________________

(Pangalan ng Taong Nais Ireklamo)

Particulars of Complaint (Detalye ng Reklamo):

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Signature (Pirma)