STATE OF IOWA

IOWA DEPARTMENT OF ADMINISTRATIVE SERVICES
GENERAL SERVICES ENTERPRISE - PROCUREMENT SERVICES

Hoover State Office Building, Level A

Des Moines, IA 50319-0105

CUSTOMER COMPLAINT REPORT

Complete this form to report complaints pertaining to vendor performance/service,

product or unsatisfactory service to General Services Enterprise - Procurement Services.

Agency		Customer
Address		Address
Telephone		Agency Requisition Number	PO Number
Product Covered by Complaint		Contract Award Number	Brand Name
Date Product Received	Date Product First Utilized	Invoice Number	Code Number

NATURE OF COMPLAINT

QUALITY/QUANTITY
	Quality of product inferior
	Unsatisfactory/unauthorized substitute made
	Unsatisfactory workmanship in installation
	Damaged or defective
	Product lacks required inspection or grade certification
	Product received was not same as bid or sampled
	Less than ordered
	More than ordered
	Other - Specify:

DELIVERY
	Delivery not made within specified delivery
	FOB point not as specified on purchase order
	No notice of delayed delivery
	Received in damaged condition oCarrier notified
	Incorrect shipping address
	Partial delivery - cannot deliver balance of order
	Excessive partial shipments
	Non-delivery
	Method not as specified, before/after hours
	Other - Specify:

OTHER

Improper labeling

Unsatisfactory packing

Failure to resolve complaint properly

Invoice inaccuracies

Service deficiencies

Other - Specify:

REMARKS:

Give detailed, specific, factual explanation of complaint in this space. Attach additional sheet if necessary.

RECOMMENDATION for settlement of complaint:

oFor your information oFor return and reimbursement of product

Complaint Executed By:

Name:		Title:
Phone:	FAX:			Date:
Complainant notified of disposition:			Yes		No

AGENCY USE ONLY

Disposition of Complaint:
Purchasing Agent:	Date:

updated 12/14/07