VI DLCA Web APP

You are filing a complaint against a business

Complainant/Contact Information

Validation Error

You must correct the following error(s) before proceeding:

Anonymous - Complainant providing information to DLCA only. [If you have checked this box, No need to provide Name/address/contact information.] * Required field

* First Name:		* Last Name:
* Address1:		Contact Phone #:
Address2:		Email:
* City:
* Country:		Province:
* State:	* Zip:
Island:

Business Information

* Street1:		Street2:
* City:
* Country:
* State:	* Zip:

Please type Business Name OR Trade Name OR Owner Name in the search box then click Search. If the business is registered with DLCA, you will find it in the drop down list.Select it.
[Min 4 chars]
Select a Business from the drop down list to the right

Product/Service Information

Description	Cost	Purchase Date	Receipt #
				Delete

To add additional items (more than one) pl click

Complaint Information

* Complaint Description[Max 2000 characters]

* Did you try to resolve the issue with the business/individual? Yes No

* Who did you complain to?

* What was their response?[Max 2000 characters]

* How do you want this complaint resolved?[Max 2000 characters]

* Did you sign any documents/agreements/contracts? Yes No