Farm Implements Act Program - Complaint Form

(Please print or type all information)

Name: ____________________________________________________________

Address: __________________________________________________________

__________________________________________________________________

City, Province: ______________________________________________________

Postal Code: _______________________________________________________

County: ___________________________________________________________

Telephone No. (Please indicate the best time to call): _______________________

__________________________________________________________________

I request assistance from the Farm Implements Act Program with the following problem:

Type of Machine: ____________________________________________________

Make: _____________________________________________________________

Model: _____________________________________________________________

Year: ______________________________________________________________

Date Purchased: _____________________________________________________

New/Used (Circle one)

Machine is under warranty: Yes/No (Circle one)

Total Use of Machine -

Hours: _____________________________________________________________

Acreage: ___________________________________________________________

Purchased from/repaired by: ___________________________________________

Registration No.: _____________________________________________________

Address: ___________________________________________________________

__________________________________________________________________

City, Province: ______________________________________________________

Postal Code: _______________________________________________________

County: ___________________________________________________________

Telephone No.: ______________________________________________________

Approx. value of Machine ($): ___________________________________________

Approx. dollar amount involved in complaint ($): ____________________________

Nature of problem (Please continue on back or on a separate sheet if necessary):

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

Signature: __________________________________________________________

Please fax completed form to:

Finbar Desir at 519-826-6611

or mail to:

Finbar Desir - Farm Implements Coordinator
Environmental Management Branch
1 Stone Road West, 3SE
Guelph, ON N1G 4Y2

For Department Use Only:

Complaint No.: ______________________________________________________

Complaint Type: _____________________________________________________

Status: ____________________________________________________________

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