Date:

GENERAL INFO

Name of Complainant:




First NameMiddle Name Surname

Complaining
for:


Male Female Date of Birth:



Social Security: Nationality:


Residential and/or mailing address:

Street: P. O. Box:

Town/City/District: Country:


Tel. Nos.: (501) - - Fax: (501) - -

Email:

Occupation:



ALLEGED WRONG-DOING (BRIEFLY DESCRIBE):


Date of Wrong-doing:

Location of Wrong-doing:



AUTHORITY (ALLEGEDLY) CAUSING INJUSTICE:

Ministry: List Officers:


Department:

Injustice suffered:

Visited Emergency Room? Yes or No Consulted Medical Practitioner? Yes or
No

Retained Attorney? Yes or No Ongoing Court Proceedings? Yes or No

Name of Attorney: Court:



Additional Note (anything else you may find important to mention):


Submit this form to Ombudsman or Authorized Agent by filling it out, attaching it to
your email and sending it to ombudsman@btl.net.








Office of the Ombudsman
Digital Complaints Form
Select... Select...
Select...
Select...
Select...




Date:
GENERAL INFO

Name of Complainant:




First NameMiddle Name Surname

Complaining
for:


Male Female Date of Birth:



Social Security: Nationality:


Residential and/or mailing address:

Street: P. O. Box:

Town/City/District: Country:


Tel. Nos.: (501) - - Fax: (501) - -

Email:

Occupation:



ALLEGED WRONG-DOING (BRIEFLY DESCRIBE):


Date of Wrong-doing:

Location of Wrong-doing:



AUTHORITY (ALLEGEDLY) CAUSING INJUSTICE:

Ministry: List Officers:


Department:

Injustice suffered:

Visited Emergency Room? Yes or No Consulted Medical Practitioner? Yes or
No

Retained Attorney? Yes or No Ongoing Court Proceedings? Yes or No

Name of Attorney: Court:



Additional Note (anything else you may find important to mention):


Submit this form to Ombudsman or Authorized Agent by filling it out, attaching it to
your email and sending it to ombudsman@btl.net.








Office of the Ombudsman
Digital Complaints Form
Select... Select...
Select...
Select...
Select...