STORE FORM

STORE BRANDS RETAIL/STORE CONCERNS

Date:

STORE INFORMATION:

Store Name:
Contact Person:
Address:
City:			State:		Zip:
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:		Case Count :

ISSUE:

Nature Of Claim:
Has product been pulled from shelf:		Yes	No	Date Pulled :
Has credit been issued to store:		Yes	No	Date Issued :

ROUTE VIA ONE OF THE FOLLOWING OPTIONS:
E-MAIL TO: genie.m.nicholas@supervalu.com	MAIL TO: GENIE NICHOLAS, QA MANAGER
PHONE TO: GENIE NICHOLAS @ (952) 294-7749	DAYMON ASSOCIATES, INC.
FAX TO: GENIE NICHOLAS @ (952) 294-7494	19011 LAKE DRIVE EAST
	CHANHASSEN, MN 55317

ADDITIONAL COMMENTS: