Public Protector Complaints Form

Please fill out the Complaints form to the best of your ability to allow the Public Protector to follow up on the problem.

YOUR DETAILS

1. Your Name

Title:

Surname: Initials:

2. If your complaint is about a pension or ID document matter, please provide your ID number.

ID number:

3. Your address and telephone number(s)

The address where you live:

     Postal Code:

The address we can send letters to:

     Postal Code:

Telephone number at home:
Code:    Number:

Telephone number at work:
Code:    Number:

Is there any other telephone number we can call you at:
Code:    Number:

Whose telephone number is this?:

Fax number:
Code:    Number:

Cellular phone:
Number:

4. If this complaint is for someone else, please tell us about them.

Title:

Surname: Initials:

5. Their ID number if the complaint is about a Pension or ID document matter.

ID number:

6. Their address and telephone number(s)

The address where they live:

     Postal Code:

The address where we can send letters to:

     Postal Code:

Telephone number:
Code:    Number:

Fax number:
Code:    Number:

7. If this complaint is for an organisation, please tell us:

The name of the organisation:

What does it do (e.g., Civic, NGO, Business, Retailer, Factory):

Who should we talk to there:

What is their position (e.g. Colleague, Chairperson, Director, Secretary):

The address we can send letters to:

   Postal Code:

Telephone number:
Code:    Number:

Fax number:
Code:    Number:

TELL US ABOUT THE COMPLAINT

8. Is the problem still happening?

9. If no, on what date did it happen?

Day Month Year What Time?

10. Where did it happen?

Town
Province

11. Which Government agency is involved?

12. Tell us the names of the officials that you contacted to try and solve the problem:

13. Where can they be reached?

14. Have you reported this case to anyone else?

If yes, who (e.g. the police, a lawyer)

15. Please tell us how you heard about the Public Protector (radio, newspaper, poster, friend):

16. In this space provided below and in your own words, tell us exactly what happened, including all the information which you think is important.

Date: 2010/01/22

Thank you for completing this form. We will communicate with you as soon as possible.

Public Protector