Participant Vendor Dissatisfaction Form

Please use this form if a vendor is consistently at fault for any of the following and/or you would like to inform us of any dissatisfaction you experienced with a vendor. Please be assured the information you submit to us is confidential. We will notify you at an appropriate time when action is to be taken. In order to "Submit" this form, please use the Mozilla Firefox or Google Chrome browser. Any fields noted with a * are required.

	Your Information

	Full Name*

	School District/Department/Program Name*

	Phone Number*

	E-mail Address*

	Vendor Information

	Vendor Name*

	Address (City, State, Zip Code)*

	Purchase Order Number

	Purchase Order Date

	Details of Complication/Incident

	Bid:*
	--Please Select--Arts & Crafts SuppliesAthletic/Academic Supply and Equipment ReconditioningAudio Visual Supplies & EquipmentCarpentry ServicesClassroom FurnitureCurricular PaperCustodial SuppliesElectrical LampsTubes & BallastsElectrical ServicesFence EquipmentAccessoriesRelated Site-Work ImprovementsFine & Recycled PaperFire Extinguisher MaintenanceFuel OilGeneral Office SuppliesGlass ReplacementHazardous Waste Removal and DisposalHVAC ServicesInspectionPreventive Maintenance & Repair of Basketball BackstopsInspectionPreventive Maintenance & Repair of BleachersLabels & Report CardsLead in Water AnalysisMicrocomputersPeripherals & SoftwareMusic Supplies & InstrumentsMusical Instrument RepairsPaint & Paint SuppliesPainting ServicesPhys. Ed/Athletic/First Aid SuppliesPlumbing ServicesRecycling CollectionScience Supplies & Graphing CalculatorsSecurity ServicesSpecial Education Instructional SuppliesStationery SuppliesTank TestingRepair & CleaningTechnology EducationThird Party Administrator for Tax Sheltered AnnuitiesOther

	ESBOCES Bid (Quote) Number:

	List Item Number(s):

	Nature of Dissatisfaction:*
	Delivery not made on order as promised    Delivery made to wrong destination    Unauthorized delivery made before issuance of order    Quality of commodity is inferior    Unsatisfactory workmanship in installation of commodity    Invoice price higher than authorized    Quantity delivered in excess of order    Delivery made at unsatisfactory hour    Improper method of delivery    Delivery in damaged condition    Unauthorized substitute delivered by vendor    Commodity lacks required inspection stamps    Weight received at variance with invoice    Quantity delivered less than ordered    Other - please specify

	Has the vendor been contacted via telephone more than once?
	Has the vendor been contacted via telephone more than once? YesNo

	Is this information for Documentation purposes only?
	Is this information for Documentation purposes only? YesNo

	Description of item(s):*

	Department/Program Comments: (Please be accurate, complete and factual, and in addition, indicate the manner in which you suggest your complaint be settled.)