CONSUMER GRIEVANCE REDRESSAL FORUM

CGRF - KSERC REGULATION         download

CGRF of Technopark

APPLICATION FOR FILING COMPLAINT WITH THE CONSUMER GRIEVANCE REDRESSAL FORUM

1. NAME OF THE COMPLAINANT :

 

2. FULL ADDRESS OF THE COMPLAINANT:

 

PIN CODE :

 

PHONE NO :

 

FAX NO :

 

EMAIL ID :

 

3. CONSUMER NUMBER / PARTICULARS OF CONNECTION (Please state nature of connection)

 

4. NAME OF THE LICENSEE :

 

5.OFFICE OF THE LICENSEE TO WHICH THE COMPLAINT PERTAINS

 

 

6.DETAILS OF COMPLAINT / GRIEVANCE (If space is not sufficient please enclose separate sheet)

 

 

7. DETAILS OF INTIMATION OF GRIEVANCE BY THE CONSUMER TO THE LICENSEE.

 

8. WHETHER ANY REPLY HAS BEEN RECEIVED FROM THE LICENSEE (If yes, a copy of the reply to be attached)

 

9. NATURE OF RELIEF SOUGHT .

 

10. LIST OF DOCUMENTS ENCLOSED

 

11. DECLARATION I/ We , the complainant /s herein declare that: (a) the information furnished herein above is true to the best of my/our knowledge, information and belief. (b) I/ We have not concealed or misrepresented any fact stated above and the documents submitted herewith. (c) I/We have not brought the subject matter of the present complaint before this forum earlier. (d) The subject matter of the present complaint has not been decided by any oForum/ Court/Arbitrator of any other authority.

 

Yours faithfully (Consumer’s name in block letter)

 

NOMINATION

 

(If the consumer wants to nominate his representative to appear and make submissions on his/her behalf before the Forum, the following declaration should be submitted.)

 

I/We the above named consumer hereby nominate Shri/Smt

 

and whose address is

 

as my/our representative in the proceedings and confirm that any statement, acceptance or rejection made by him/her shall be binding on me/us. He/She has signed below in my presence.

 

Please make a selection.

 

ACCEPTED

 

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