First name of person submitting complaint*

Last name of person submitting complaint*

Merchant Business Name*

Merchant ID*

Phone number*

Merchant Street address*

Province/Territory*

City*

Postal code*

Email*

Name of acquirer*

Date merchant spoke with acquirer*

Month/Day/Year

Name of downstream participant*

Merchant Number*

Name of acquirer representative*

The policy element of the Code that the complaint pertains to*

Description of Issue or Complaint

Submit