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NBN & Internet Complaint Information

Please complete the form with as much detail as possible.

First Name

Last Name

Email

Business Phone

Mobile Phone

Company/Business Name of Account Owner

ACN/ABN

Business Address

Street Address Line 2

City

Region/State/Province

Post Code

Number of Services Provided

Account Number

Date Contract Commenced

Monthly Plan Charges

Current Account Balance

Dispute

Have you spoken to your provider regarding these issues?

Yes

No

Date of First Contact

Date of Most Recent Contact

Details of First Contact Conversation

Do you have any communications from your provider?

Yes

No

Have you lodged a formal complaint with your provider or anyone else?

Yes

No

If yes, please provide the details of who you lodged your complaint with?

Do you have a reference number for your complaint?

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What resolution did you propose or do you seek?

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