Information on Competition Problems affecting Consumers

to the Consumer Liaison Office

Please complete all the compulsory fields. These are marked with a square(#). No files or documents can be attached to this form. If you do require to make attachments please send them by separate mail to the address at the foot of this page, together with a printed copy of the form or use the attached file.

Your personal details

First Name:(#)		Last name:(#)
Address line 1(#):		Address line 2:
Town/City:(#)
Postcode:(#)		Country:(#)
Telephone		Mobile Telephone:
E-mail address:		Fax:

1. About which Undertaking or Group do you wish to inform?#

2. To what economic sector is your information related? Please chose one: #

If "Other", please specify:

3. What is the matter about which you inform? When did it come to your attention?#

4. What result do you hope to achieve?#

5. Have you already contacted the Directorate General for Competition or other National Competition Authorities or National Regulators in order to obtain assistance? #
Yes No (If yes, please specify)

Agreement

6. Do you agree that your information may be passed on to another national competition authority, if we are not entitled to deal with it?#
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