for Contractors/Vendors for Government Entities for State Employees for the Public

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INSTRUCTIONS:  Complete this form to reference complaints concerning Vendor's unsatisfactory performance, products, and services.  This COMPLAINT TO VENDOR shall become a permanent record of the vendor's performance.  The information furnished herein must be complete and accurate to determine the appropriate course of action.

Note:  If this complaint is not resolved within one week of filing with the Office of Procurement Services, please notify this office immediately.

Date of Complaint: 
Vendor Name: 
Vendor Address:
Vendor (City,State, Zip):


P.O. Number and P.O. Date:   
Requisition #:   
One-Time Bid or Contract Number:   
Department or Agency:
Management Representative of Dept/Agency: 
Management Representative Phone #:   (ex. 555-555-5555)
Complainant Title and Name:  
Complainant Phone #:                          (ex. 555-555-5555)
Complainant Email: 

Contractor Email: 

          Day(s) Delinquent:      


(State Persons and Dates Below)
         (State Results Below)

Specific Detail:
Include the history of what steps the agency has taken to resolve this issue.



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