Republic of the Philippines
DEPARTMENT OF TRADE AND INDUSTRY
Cebu Provincial Office 3/F LDM Building, Legaspi Street, Cebu City
Phone: (6332) 2557084, 2557086 Fax: (6332) 2557609

CONSUMER ARBITRATION OFFICE
Date:

For:
(Violation Case No.)     
 
Consumer/Complainant Information

 

Complete Name:
 
Last
First
Middle
  
Home Address:
Home Phone:
(6332)
Office Address:
Office Phone:
(6332)
E-mail Address:
Fax Number:
(6332)
       
Company/Respondent Information
       
Company/Respondent Name:
Address:
Phone Number:
       
Complaint Information
       
Date problem first occurred:
Date(s) you contacted the Company: To Whom :
What action was taken?
Name of Product/Service involved: Cost:
Brand Name: Model Name/No:
Date Purchased:
Official Receipt, Invoice No., Order, Contract, Acct. or Policy No.:
Name of Salesperson:
       
Nature of complaint (Check corresponding box)
       
Product & Service Warranties
Breach of Product Warranty
Breach of Service Warranty
Other Conditions: Brand New/Surplus/Second Hand
Acts Complained:
Unfair/Unconscionable Sales Acts or Practice (check out Frequently Asked Questions)
Deceptive Act Committed:
Sales Promotion Violation (check out Frequently Asked Questions)
Title of Promotion: Promo Duration:
Sponsor:
Nature of Violation: Non-receipt of Prize Deviation from Mechanics No Permit
Other Trade Fair Law Violations
Describe your complaint in detail and in chronological order (by date).
Description of Complaint
Payment Information
Have you already paid for the product or service? Yes No Partial Payment
Price/Amount in Dispute:
Method of Payment: Cash Check Credit Card Money Order
What settlement would you consider fair?
refund
Repair
Replacement
Regulatory
Others:
Have you contacted any other agency for help in resolving this complaint? Yes No
If yes, please provide details.
 
 
 
________________________________
Complainant's Signature           
       
Documents Submitted:
 
SUBSCRIBED AND SWORN to before me this day of , 20 at Cebu City, Philippines.
 
 

___________________________________
  Administering Officer                

 

 
VERIFICATION AND CERTIFICATION
 

I, , Filipino, of legal age, and a resident of , after having been duly sworn to in accordance with law, do hereby depose and say, that:

  1. I am the Complainant in this case;
  2. I have prepared and/or caused the preparation of the foregoing Complaint;
  3. I have read the same, and the truth of which are true and correct of my own knowledge;
  4. I hereby certify that I have not commenced any other action or proceeding involving the same issues in this case before the Department of Trade and Industry and/or different bureaus, divisions and office thereof, or any other tribunal or quasi-judicial agency, and to the best of my knowledge no such action or proceeding is pending in any of the aforesaid bodies, tribunal or agency, so, if there is any action or proceeding that I may learn in the future I am willing to report and inform this office of the matter immediately.
IN WITNESS WHEREOF, I have hereunto set my hand and affixed my signature this day of , 20 at Cebu City, Philippines.
 
 
___________________________________
     Administering Officer