Electronics Product Complaint Log Form
Use this form to log an electronics product complaint, describe the product and issue, and state the resolution you want.
Complaint Reporter Information
Full Name
*
First Name
Middle Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
*
Email
Phone
SMS
Electronics Product Details
Product Name / Model
*
Product Category / Type
*
Please Select
Smartphone
Laptop
Tablet
Television
Audio Device
Appliance
Other
Serial Number / Device Identifier
Purchase Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Place of Purchase / Store or Order Reference
Complaint Issue and Resolution Request
Complaint Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Issue Description
*
When Did the Issue Start?
*
Troubleshooting Already Attempted
Impact / Severity
*
Minor
Moderate
Major
Device unusable
Desired Resolution
*
Repair
Replacement
Refund
Technical Support
Other
Submit Complaint
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