Consumer Protection Division - Complaint Form

Mississippi Department of Agriculture & Commerce

Complainant Information

Applicant	#field(17102) #field(17103)
Address	#field(17104)#if(#field(17105)) #field(17105)#endif #field(17106), #field(17107) #field(17108)#if(#field(17109)) #field(17109) County#endif
Telephone	#field(17110)
Email	#field(17111)

Business / Store Information

Business / Store Name	#field(17113)
Date of Incident	#field(17114)
Store Address	#field(17115)#if(#field(17116)) #field(17116)#endif #field(17117), #field(17118) #field(17119)#if(#field(17120)) #field(17120) County#endif

Nature of Complaint and Details

#if(#field(17124))#endif

Type of Complaint	#if("#field(17123)" = "Spoiled Fresh Food")Spoiled Fresh Food#endif#if("#field(17123)" = "Sanitation conditions or Foul odor")Sanitation conditions or Foul odor#endif#if("#field(17123)" = "Rodents or Insects")Rodents or Insects#endif#if("#field(17123)" = "UPC Pricing or Overcharges")UPC Pricing or Overcharges#endif#if("#field(17123)" = "Product Weight")Product Weight#endif#if("#field(17123)" = "Catfish Labeling")Catfish Labeling#endif#if("#field(17123)" = "Seafood Labeling")Seafood Labeling#endif#if("#field(17123)" = "Other")Other#endif
Other Detail	#field(17124)
Complaint Details	#field(17125)

Submit ID: #submit_id