Consumer: Gas Price Complaint Form

	Arizona Attorney General: Antitrust Unit
	Gasoline Price Complaint Form

Consumer's Information
First Name:	[required]
Last Name:	[required]
Address:
City:
State:
Zip:
Phone:
e-mail address:

Gasoline Station's Information
Name:	[required]
Address:	[required]
City:	[required]
State:
Zip:
Phone:	(if known)

Details of Purchase
Grade of Gasoline Purchased:	[required]
Price per Gallon Paid:	[required]
Total Dollar Amount of Purchase:
Date of Purchase:	[required]
Time of Purchase:

Comments:

Statistical Information

How did you hear about our complaint form:

Called Phoenix AG Office
Called Tucson AG Office
Went onto AG Website
Visited an AG Satellite Office
An Out of State Agency
Media: Newspaper/Radio/TV
Another Arizona State Agency/State Legislator
Attended AG Presentation/Event
Other

Arizona Attorney General: Antitrust Unit

Gasoline Price Complaint Form

Thank you for taking the time to complete this form.