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Business Licensing Services
Customer Complaint Form
C
OMPLAINT REPORTED BY: COMPLAINT REPORTED AGAINST:
Name: ______________________________________________
Address:_____________________________________________
City:________________________________________________
State: ___________________________ Zip:________________
Home Telephone Number: ______________________________
Cell Telephone Number: ________________________________
Work Telephone Number: _______________________________
Email Address: _______________________________________
*Note: By providing your email-address, you agree to receive
communication from this office by e-mail
Business Name: ______________________________________
Address:_____________________________________________
City:________________________________________________
State: ___________________________ Zip:________________
Telephone Number: ______________________________
Date of Incident: ______________________________________
**At a minimum, you must provide the business location or print the
location of where the purchase or service transaction occurred.
1. Type of Business [Please check the appropriate box(es)]
□ Autobody Repair Facility □ BAIID Installer □ Dealership
□ Driving School □ License Leasing Company □ Remedial Driver Education Program
□ Window Tinting Company □Other: Specify ___________________________________________________
2. If your complaint involves the purchase of a motor vehicle, pleas provide the following information:
a. □ New Vehicle □ Used Vehicle
b. □ Purchased in Full □ Financed □ Leased
c. Date of Purchase: _____________________________ Current Mileage: _______________________________
d. Purchase Price: _____________________________
□ With Warranty □ With Service Contract □ As Is
e. Year:__________________________ Make: _______________________ Model: __________________________________
f. VIN#: _______________________________________________________
3. N
ame and Title of Employees you dealt with: Name: ____________________________ Title: __________________________
Name: ____________________________ Title: __________________________
Name: ____________________________ Title: __________________________
On the Road to Excellence
Visit us at www.njmvc.gov
New Jersey is an Equal Opportunity Employer
Business Licensing Services Bureau
P.O. Box 170
Trenton, NJ 08666-0170
(609) 984-1122 (Office)
(609) 777-3769 (Fax)
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4. D
escribe the facts of your complaint in the order in which they happened. Use additional sheets of paper, if necessary. Attach readable
copies (not originals) of any complaint-related documents, bills, receipts, correspondence, and/or any other documents provided to yo
u
by
the business or related to your complaint.
Type or print your response clearly.
I c
ertify that the foregoing statements made by me are true. I understand that if any of the statements made by me are willfully false, I am
subject to administrative, civil or criminal penalty. I authorize the New Jersey Motor Vehicle Commission to investigate the information
provided in any way necessary.
__________________________________________________________
________________________________
Signature of person completing this form Date
*
*Note: You may fax (609) 341-3314 or email ([email protected]
) your complaint.
Include the total number of pages:
Total # Pages:____________________________
BLS-161 R 7/23
