CONSUMER FORM

STORE BRANDS CONSUMER CONCERNS

Date:

CONSUMER INFORMATION:

Prefix:		First Name:			Last Name:
Address:
City:			State:		Zip:			Phone:
Email:

PRODUCT INFORMATION:

Store Brand Name:		Product Name:
Product Code: (Jar/Cap, Can/Lid, Box/Flap)		UPC Code :
Supplier Name:		Plant/Establishment Number :
Distributor Name:

ISSUE:

Nature Of Claim:
Illness/Injury Involved:	Yes	No		Refund Amount :

STORE INFORMATION:

Store Purchased :			Location:
Manager Name:		Phone:		Email:
Daymon Rep:		Phone:		Email:

ROUTE VIA ONE OF THE FOLLOWING OPTIONS:
E-MAIL TO: Linda.Smith@fedgroup.com	MAIL TO: LINDA SMITH @ FEDERATED GROUP
PHONE TO: LINDA SMITH @ (877) 658 3581	3025 WEST SALT CREEK LANE
FAX TO: LINDA SMITH @ (847) 632-8412	ARLINGTON HEIGHTS, IL 60005-1096

ADDITIONAL COMMENTS: