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Note: (*) are required input
About yourself
First name *
Last name *
Country or region *
Your address(Line 1)  
Your address(Line 2)  
Sex *
 Female
Occupation  
E-mail address *
Primary telephone  
 ext.
xx-xxx-xxxx
About the company
Name of company *
Company e-mail address *
Company website(URL) *
If the transaction was through a online auction service, please enter the auction site address.
About the transaction
Goods or service purchased *
Cost of purchase *
If "other" please enter currency type in "Complaint Details".
Date goods/service ordered    Do not remember
Date you received   Not yet received
Method of payment * Others
Date you paid   Not yet paid
Complaint details *  (Please be as specific as possible.)
Questionaire (How did you find us?)

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