Republic of the Philippines

Office of the President

National Telecommunications Commission

ONE STOP PUBLIC ASSISTANCE CENTER

Bir Road, East Triangle, Diliman,Quezon City

COMPLAINT FORM

On Various Service Providers (TELCOS & Broadcasting)

Reference Number:____________________

I. COMPLAINANT DETAILS:

Name :______________________________________________________

Address :______________________________________________________

______________________________________________________

Contact Number : ______________________________________________________

_______________________________________________________

II. RESPONDENT DETAILS::

Name/ :_______________________________________________________

Address :_______________________________________________________

Contact number :_______________________________________________________

III. NATURE OF COMPLAINT:

( ) Billing Complaint

( ) Poor Services

( ) Others, Pls Specify ; __________________________________________________

________________________________________________________

IV. NARRATION OF COMPLAINT:

V. PROOFS / EVIDENCES ( ATTACHED):

__________________________________________________________________________________

__________________________________________________________________________________

___________________________________

COMPLAINANT

SIGNATURE OVER PRINTED NAME