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Sample Complaint Form

Consumer or employee uses sample complaint form to record grievance experience. It enables business organizations to improve weak points of their businesses. I have designed a sample complain form for you. It is absolutely free and easy to edit therefore after some modifications you can easily use it as your business document.

Sample Complaint Form

In order for the PCM to address your complaint, you must provide the following information:

1. Name of the Person(s) or Organization(s) filing the Complaint (“the Complainant”).

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2. Contact information of the Complainant (please includes email address and phone number if possible).

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3. Is there a representative making this Complaint on behalf of the Complainant?

Yes (   )  (if yes, please provide the Name and Contact information of the Representative):

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Please attach proof that the Representative has been authorized by the Complainant to file the Complaint.  For example, this can be in the form of a

letter signed by the Complainant giving permission to the Representative to make the Complaint on his behalf.

No (   )

Is proof of authorization included with the Complaint?

Yes (   )     No (   )

4. Are you requesting that this Complaint be kept confidential?

Yes (   ) (if yes, please explain why you are requesting confidentiality)

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No (   )

5. Please provide the name or a description of the EBRD Project at issue.

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6. Please describe the harm that has been caused or might be caused by the Project (please continue on a separate

sheet if needed):

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7. If you are requesting the PCM’s help through a Problem-solving Initiative, you must have made a genuine effort to

contact the EBRD or Project Sponsor regarding the issues in this complaint.

a. Have you contacted the EBRD to try to resolve the harm caused or expected to be caused by the Project?

Yes        (If yes, please list when the contact was made, how and with whom):

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Please also describe any response you may have received.

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No        (please go to question 8)

Is the written record of this contact with the EBRD attached to your complaint?

Yes



(please list) 

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No (   ) (if not, please arrange for all relevant documents to be delivered to the PCM Officer as soon as possible).

b. Have you contacted the Project Sponsor to try to resolve the harm caused or expected to be caused by the Project?

Yes (   ) (if yes, please list when the contact was made, how and with whom)

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Please also describe any response you may have received.

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No (   ) (please go to question 8)

Is the written record of this contact with the Project Sponsor attached to your complaint?

Yes (  ) (please list)

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No (  ) (if not, please arrange for all relevant documents to be delivered to the PCM Officer as soon as possible).

8. If you have not contacted the EBRD and/or Project Sponsor to try to resolve the harm or expected harm, please

explain why.

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9. If you believe the EBRD may have failed to comply with its own policies, please describe which EBRD policies.

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10. Please describe any other complaints you may have made to try to address the issue(s) at question (for example, court cases or complaints to other bodies).

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11. Are you seeking a Compliance Review where the PCM would determine whether the EBRD has failed to comply with its Relevant Policies?   Yes  (   )      No  (   )
12. Are you seeking a Problem-solving Initiative where the PCM would help you to resolve a dispute or problem with the Project?  Yes (   )    No (   )
13. What results do you hope to achieve by submitting this Complaint to the PCM?

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Required: _____________________________________

Signature of Complainant *: ______________________

Or

Signature of Authorised Representative *: ___________

 

Date: _____________________

 

Please send your Complaint to:

Project Complaint Mechanism

Attn: PCM Officer

ABC Reconstruction and Development

One Exchange Square

London EC2A 2JN

Fax: +44 20 5697 8651

E-mail: abc@example.com

Alternatively, a Complaint may be delivered by post or hand, at any one of the EBRD’s Resident Offices, indicating that it is for transmission to the PCM.

Note: If you submit your complaint through email, you must submit:

  • An electronic scan of your signature; or alternatively,
  • If emailed without a scan, you may send the PCM a signed version of the complaint through post, fax, or hand delivery at the same time as sending your email.
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