Complaint Form

Complaint Form

Part A – About you

Fill in this box if you if you are making a complaint
Name of person*
Name of nominee if applicable
Street Address
City
State
Mobile
Email
Date complaint lodged
DD slash MM slash YYYY

Fill in this box if someone is assisting you with the complaint – for example a family member, your nominee or representative.
Name of representative
Organisation
Street Address
City
State
Contact Numbers
Business
Mobile
Email
My preferred contact is

Part B – Your complaint

What is your complaint about?
Provide some details to help us understand your concerns. You can include what happened, time and date, where it happened and who was involved.

Part C – Who is your complaint about?

Who or what does your complaint relate to
Name/organisation*
What is this person’s/organisation’s relationship to you?*
What outcomes are you seeking?
Supporting information such as witness names, photos and correspondence or emails etc
Upload Files or Photos
Max. file size: 64 MB.
Upload Files or Photos
Max. file size: 64 MB.