Enquiry reference number: (Office use nly) Administered by the Centre fr Effective Dispute Reslutin (CEDR) APPLICATION FORM What is this Applicatin fr? What d I need t d? This applicatin frm is fr custmers t bring a claim against a cmmunicatins prvider that subscribes t CISAS. The applicatin frm will ask yu fr the details needed t understand what yu wuld like the cmpany t d and decide yur dispute. Applicatins can nly be accepted after yu have given the cmmunicatins prvider a perid f at least 8 weeks in which t address yur cmplaint, r at any time after the prvider cmmunicates t yu that they have reached deadlck. Read the Rules and the Guidance fr Custmers fact sheet. If yu are unsure f hw t answer a questin please cntact CISAS fr guidance. Fill in the applicatin frm giving as much infrmatin as yu can. It may take yu sme time t g thrugh the applicatin frm and get all yur facts tgether but having all the infrmatin will help CISAS assess yur case fairly. Yu must prvide evidence t prve yur claim. Please let us knw if yu have any practical needs where we culd help fr example with infrmatin in anther frmat (e.g. larger print) r in anther language. If yu require assistance in cmpleting this frm please cntact: By telephne: 0207 520 3814 By email inf@cisas.rg.uk Visit the website www.cisas.rg.uk CISAS pening hurs: 9:00am t 5:00pm, Mnday t Friday 1. Abut yu Please prvide yur full cntact details. If yur accunt with the prvider is held under a different name (e.g. married name) please prvide thse details. Full name: Organisatin (if applicable) Street Address: Twn: Cunty: Pst cde: E-mail address: Tel: If yu prvide an e-mail address we will send yu infrmatin by e-mail nly. 2. Yur Dispute Please prvide sme infrmatin n the service(s) that yur dispute relates t. Details f the ptins t chse frm are listed n the last page. Which prvider des yur dispute relate t? Des yur dispute relate t a residential r business accunt? Select What service type des yur dispute relate t? Select Which f the ptins best describes the nature f yur dispute? Select
3. Abut yur accunt Accunt hlder name: Mbile / Landline number(s): Accunt Number(s): Have yu raised yur cmplaint with the cmmunicatins prvider directly? Yes N Has 8 weeks elapsed since yu made yur cmplaint? Yes N On what date did yu first cmplain t the prvider? If yu are a business custmer, hw many emplyees are in yur business? 4. Managing yur cmplaint Yu may elect t have a representative act fr yu (at yur wn cst). If yu chse t d this, please prvide their full cntact details belw. Full name: Organisatin (if applicable) Street Address: Twn: Cunty: E-mail address: Pst cde: Tel: T be signed by the applicant named in sectin 3 if represented. I hereby give my authrity fr the abve named persn t represent me: Print name: Signature: Date: CISAS Applicatin Frm Page 2
5. Deadlck letter The cmmunicatins prvider may have sent yu a letter r email headed written ntice, final respnse r deadlck letter. A deadlck letter is a cmmunicatin frm the prvider that tells yu that yu have reached the end f their cmplaints prcedure and that the dispute cannt be reslved. Have yu received a deadlck letter? Yes N What is the date n the deadlck letter (if received)? What is the reference number n the deadlck letter? Did the deadlck letter mentin CISAS? Yes N 6. Hw did yu find ut abut CISAS? CISAS website Prvider Ofcm Online frum Scial media Other (please specify) 7. Yur cmplaint Please prvide the details f the issues yu have experienced and ensure that yu: Prvide as much relevant detail as yu can; Ensure yu prvide evidence, written r therwise, that supprts yur claim; Use additinal pages if required. This is yur pprtunity t submit a fully detailed written claim and prvide supprting evidence. Yu cannt make additinal claims r submit further evidence at a later date. 7.1. The Cntract Please tell us what gds and services, prvided r nt prvided by the prvider this dispute relates t (e.g. bradband, mbile phne, VIP): CISAS Applicatin Frm Page 3
7.2. Issues in Dispute: Tell us in mre detail what exactly yu are in dispute with the prvider abut. (Please cntinue n separate sheets if required): Evidence In rder t prve yur claim yu must submit evidence that supprts yur psitin. Where pssible yur evidence shuld be submitted in chrnlgical rder. Yu may wish t prvide any f the fllwing evidence: A cpy f the agreement r cntract yu had with the prvider. Invices and/r receipts fr the cst f the prduct and/r service. Letters and/r email cmmunicatins with the prvider Phtgraphs. Price schedules. Receipts fr all expenses yu wish t claim fr. Recrdings (Audi). Screen shts f the prvider s website. Screen shts f ther websites (Cnsumer frums etc.). Terms & Cnditins f the prvider. Vide evidence. As part f the adjudicatin prcess, a cpy f yur applicatin and all submitted evidence will be sent t the cmmunicatins prvider cncerned in rder fr them t respnd t the claims yu have made and t submit their wn evidence in defence. A cpy f that evidence will be sent t yu. CISAS Applicatin Frm Page 4
8. What wuld yu like the cmpany t d? Please prvide details f the services, cmpensatin r ther actins that yu wuld like the adjudicatr t direct the prvider t prvide r undertake. 8.1. Give yu a prduct r service: Yes N Please prvide details f the prduct and / r service yu are seeking: 8.2. Take sme actin: Yes N What actin wuld yu like t be taken? 8.3. Give an aplgy: Yes N Please prvide details f the aplgy yu are seeking: CISAS Applicatin Frm Page 5
8.4. Pay yu cmpensatin: Yes N Yu must specify the ttal amunt claimed in this sectin if yu are asking the adjudicatr t direct the prvider t pay yu in cmpensatin. The maximum amunt yu can claim is 10,000. Yu must prvide evidence t justify the amunt claimed and yu cannt change the amunt at a later date. Item Amunt Claimed ( ) Please cntinue n a separate sheet if required but ensure that the ttal amunt yu are claiming is cmpleted in the next bx belw. Ttal Claimed: 9. Custmer s declaratin Please read these declaratins and tick all three bxes t cnfirm yu understand them befre signing this frm. I have read and understd the CISAS Rules and the guidance ntes prvided with the applicatin frm. I have nt previusly referred this dispute t a curt f law. I have tried t reslve this matter thrugh the prvider s wn cmplaints prcedure. Yur signature: Print name: Date: Nw please submit yur applicatin and supprting evidence t us: By pst: By email: By fax: CISAS 4 th Flr 70 Fleet Street Lndn EC4Y 1EU inf@cisas.rg.uk 0845 1308 117 PLEASE ENSURE THAT YOU SAVE A COPY OF THIS APPLICATION ON YOUR PC BEFORE SUBMISSION CISAS Applicatin Frm Page 6
Questin Guidance Sectin 2 What service type des yur dispute relate t? Please select the ptin that best describes the package t which the cmplaint relates frm: Landline Bradband internet Pay-Mnthly Mbile Landline & bradband internet Landline, bradband internet & Pay-TV Landline, internet, Pay-TV & pay-mnthly mbile Landline & Pay-TV Landline & pay-mnthly mbile Pay-TV & pay-mnthly mbile Bradband internet & pay-mnthly mbile Bradband internet & Pay-TV Landline, bradband internet & pay-mnthly mbile Bradband, Pay-TV, pay-mnthly mbile Landline, Pay-TV & pay-mnthly mbile Which f these ptins best describes the nature f the dispute? Please ne ptin that is the main issue in dispute frm: Billing Cntract issues Custmer service Equipment Mis-sell (Misselling a prduct r service) Security Service quality (including lss f service) Other CISAS Applicatin Frm Page 7