Weights and Measures Consumer Complaint Form

	Weights and Measures Complaint Form Maryland Department of Agriculture 50 Harry S. Truman Parkway Annapolis, MD 21401 Phone: 410-841-5790 Fax: 410-841-2765 Email: [email protected]

1.	Date Received: Please Choose Date:*

2.	Your Name:

3.	Address:

4.	Phone:

5.	Alternate Phone:

6.	Email:

7.	Would you like to be notified with the results of our investigation?
	YesNo

8.	Date of Incident: Please Choose Date:*

9.	Name of location of incident: Business Name:

10.	Business Address:

12.	Pump Number:

13.	Gas Grade: Note: Pump number and gas grade required with pump complaint.

14.	Nature of Complaint:

Submit