Energy Ombudsman complaint form

1. Details of the person making the complaint

Title Mr Ms Mrs Miss Other

Other Title (Please specify)

Surname First Name Address Suburb StateTASACTNSWNTQLDSAVICWA Post Code Telephone(business hours) Mobile Fax Email Address

Do you have a disability or other special needs?

• Yes
• No

(please specify)

Preferred LanguageInterpreter Required?

• Yes
• No