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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.

III.

RESPONDENT DETAILS::

Name/

:_______________________________________________________

Address

:_______________________________________________________

Contact number

:_______________________________________________________

NATURE OF COMPLAINT:
( ) Billing Complaint
( ) Poor Services
( ) Others, Pls Specify

; __________________________________________________
________________________________________________________

IV.

NARRATION OF COMPLAINT:

V.

PROOFS / EVIDENCES ( ATTACHED):


__________________________________________________________________________________
__________________________________________________________________________________

___________________________________
COMPLAINANT
SIGNATURE OVER PRINTED NAME

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