Complaint Form Use this form to enter in complaints taken at your store to have them sent straight to the office. No fax required Store Number*Please Select…1572 – Kauffman2101 – Brandt3613 – Troy4472 Merily Way4846 – Sidney5060 – Belle South5194 – Tipp City7694 – Broad10568 – C. Glenn11047 – Greenville North13593 – Piqua East16565 – Greenville South17655 – Belle North31987 – Piqua West33311 – Towne CentreDate of Visit* MM slash DD slash YYYY Issue*Please check the box that best explains the customer’s issue (you may select multiple) Food Quality Accuracy Poor Service Rude Service Cleanliness Other Comments*Please explain the issue above in more detail (If you selected other as your issue above, please thoroughly explain the situation)Name of Customer* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Coupon Selection*Please identify the type of coupon you would like sent to this customer (You may select multiple EVM Sandwich Large Fry Dessert Happy Meal McCafe Other Quantity*Quantity of coupons listed above (You can also list in this box a specific coupon type if not listed above)Manager's Name*Password*
