Full Text
Melanie Collette Commissioner John G. Rechner Director CAPE MAY COUNTY DEPARTMENT OF CONSUMER AFFAIRS DIVISION OF WEIGHTS AND MEASURES 4 Moore Road — DN 310/302 Cape May Court House, NJ 08210-1601 (609)886-2903 fax (609)886-2906 W&M Complaint Form Complaint Reported By: Complaint Reported Against: 1.Nature of complaint (please check the appropriate box(es)): Gas Stations Supermarkets Drug Stores Retail Stores Other (specify) Incorrect Scanner Scrap Yards Concrete & Asphalt Plants Fuel Oil Metered Delivery Liquid Propane Metered Delivery Truck and Large Capacity Scales Unit Pricing Incorrect Labeling 2, Name of company you dealt with: 3. Name and title of company agents or employees you dealt with: 4. Describe the facts of your complaint in the order in which they happened. Type or print clearly. Use additional sheets of paper, if necessary. Attach readable copies (no originals) of any complaint-related contracts, bills, receipts, canceled checks, correspondence, or any other documents you feel are related to your complaint. Name Address City Zip Code Home telephone number Work telephone number *E-mail address *NOTE: By providing your e-mail address, you agree to receive communications from this office by e-mail. Name Business Address City State Zip Code (include area code) Telephone number (include area code) (include area code) (include area code) Telephone number ---PAGE BREAK--- 5. The amount of loss involved in this complaint: $ Please provide a breakdown of these losses: I certify that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are willfully false, I am subject to punishment. I authorize the New Jersey Division of Consumer Affairs to send this complaint form to the company or to interested parties and to use the information in any way that is necessary. Signature* Date * This certification must be signed by the person completing the form.