Complaint Submission Form

*Date of Submission

*Company/Customer Name

*Customer First Name

*Customer Last Name

*Company/Customer Address

Address (cont.)

*Company/Customer City

Company/Customer State/Province

*Company/Customer Country

*Company/Customer Zip

*Company/Customer Phone Number

*Company/Customer Email

Company/Customer Complaint Reference #

*Customer Item/Product #

West Item/Product #

West Item/Product Description

*Description of Problem

*Event Date

*Awareness Date

*Where was the problem detected

Has there been any additional processing by your company (i.e washed, sterilized etc.)?

Lot / Batch #'s impacted. Document when known. If unknown, indicate unknown.

Delivery Number

Purchase Order (PO) Number

Serial #'s impacted. Document when known. If unknown, indicate unknown.

Are samples available for evaluation?

If yes, please provide shipping carrier name (I.e. FedEx, UPS etc)

If yes, please provide tracking information

West Order Fulfillment Representative

West Account Manger

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