complain Registration Form
Date:

Time:

Venue:

Speaker:
Name (full name) *
firstname middlename surname
Your answer
mobile no *
your primary number
Your answer
alternater phone/ mobile no :
please enter your second contact no so that we can contact you if your primary no is not available / out of service area
Your answer
address *
type your address here
Your answer
Email address (optional )
Your answer
Status
please tick
TYPE ( eg: AC, TV, LED, LCD, Micro-Wave, Washing-machine, DVD Player, Fridge, Dish-Washer etc etc ) *
Your answer
Brand / Company *
Your answer
model no
if you don't know model number look at the back side label of your item/appliance/device or you can leave the field blank for now we will call you to confirm model number later
Your answer
problem *
write about problem you are facing (example : no power , line on picture , sound problem , buttons not working , etc etc)
Your answer
Submit
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