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 if you live overseas enter "outside Australia" StateTASACTNSWNTQLDSAVICWAOutside Australia Post Code Telephone (business hours) Mobile Fax Email Address

Do you have a disability or other special needs?

• Yes
• No

(please specify)

Are you of Aboriginal or Torres Strait Islander origin?

• No
• Yes, Aboriginal
• Yes, Torres Strait Islander
• Yes, both Aboriginal and Torres Strait Islander

Preferred Language Interpreter Required?

• Yes
• No

Are you an International Student?

• Yes
• No
• Not applicable

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This page was last modified on: 12th December 2018
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