Consolidated Complaint Form
Please DO NOT include any personal, confidential, and/or sensitive information in your responses on this form (e.g. social security number, credit card information, health information, account number, etc.).
Customer Contact Information
Prefix
Mr.
Mrs.
Ms.
Customer Last Name
Customer First Name
Customer Middle Initial
Suffix
Select
III
IV
Jr.
Sr.
Business Name
Address 1
Address 2
City
State
Select
Missouri
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
County
Select
Adair
Andrew
Atchison
Audrain
Barry
Barton
Bates
Benton
Bollinger
Boone
Buchanan
Butler
Caldwell
Callaway
Camden
Cape Girardeau
Carroll
Carter
Cass
Cedar
Chariton
Christian
Clark
Clay
Clinton
Cole
Cooper
Crawford
Dade
Dallas
Daviess
De Kalb
Dent
Douglas
Dunklin
Franklin
Gasconade
Gentry
Greene
Grundy
Harrison
Henry
Hickory
Holt
Howard
Howell
Iron
Jackson
Jasper
Jefferson
Johnson
Knox
Laclede
Lafayette
Lawrence
Lewis
Lincoln
Linn
Livingston
Macon
Madison
Maries
Marion
McDonald
Mercer
Miller
Mississippi
Moniteau
Monroe
Montgomery
Morgan
New Madrid
Newton
Nodaway
Oregon
Osage
Ozark
Pemiscot
Perry
Pettis
Phelps
Pike
Platte
Polk
Pulaski
Putnam
Ralls
Randolph
Ray
Reynolds
Ripley
Saline
Schuyler
Scotland
Scott
Shannon
Shelby
St. Charles
St. Clair
St. Francois
St. Louis
St. Louis City
Ste. Genevieve
Stoddard
Stone
Sullivan
Taney
Texas
Vernon
Warren
Washington
Wayne
Webster
Worth
Wright
Zip Code
Ext
Customer Phone 1
Customer Phone 1
Phone Type
Select
C-Cell
H-Home
O-Office
Ext.
Customer Phone 2
Customer Phone 2
Phone Type
Select
C-Cell
H-Home
O-Office
Ext.
Customer Phone 3
Customer Phone 3
Phone Type
Select
C-Cell
H-Home
O-Office
Ext.
Customer Phone 4
Customer Phone 4
Phone Type
Select
C-Cell
H-Home
O-Office
Ext.
E-mail Address
Confirm E-mail Address
email and confirm email do not match
Business Information
Business Name
Contact Name
Address 1
*
Address 2
City
*
State
*
Select
Missouri
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Zip Code
-
Ext
Primary Phone
Primary Phone
Phone Type
Select
C-Cell
H-Home
O-Office
Ext.
Alternate Phone 1
Alternate Phone 1
Phone Type
Select
C-Cell
F-Fax
H-Home
O-Office
Ext.
Alternate Phone 2
Alternate Phone 2
Phone Type
Select
C-Cell
F-Fax
H-Home
O-Office
Ext.
Alternate Phone 3
Alternate Phone 3
Phone Type
Select
C-Cell
F-Fax
H-Home
O-Office
Ext.
Type of complaint
*
Select Complaint Type
Anhydrous Ammonia Complaint
Fuel Complaint
Lubricant Complaint
Propane Complaint
Upload
Please upload document
Upload Name
JPEG , JPG , PDF
0%
Signature
By checking this box, I certify this information is correct and I have read and agree to the terms & policies.*
Legal Name
Date 10/07/2024
Confirmation Message
Are you sure you want to reset this form?
This will clear out all fields
Error Message