Service/Product Comment Form

Please use this form to report issues on products or services (positive or negative) related to any vendor, manufacturer, or distributor doing business with Multi Region Purchasing Co-op. Please provide as much information as possible and include any pictures taken of the product or packaging as necessary.

Co-op Member: Date:

Member Contact Name:

Name of Vendor/Distributor: Brand:

Product Name: Product Code:

Date Received: Date Used:

Production Date Found on Box Label:

Comments:

Have you reported this to the vendor/distributor rep? YES NO (circle or highlight one)

Vendor/Distributor Rep Name: Date Reported:

Co-op Member Signature:

Phone #: Email:

Fax or Email to: Keri Warnick Office use only: Fax: 972.348.1449 Date Rcvd: [email protected] Initials: