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* 1. Your Name

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* 2. Address, City & Zip Code (optional)

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* 3. Phone Number

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* 4. Email Address

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* 5. Would you like to be contacted by Goodwill staff regarding this complaint?

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* 6. Date of event related to the complaint/grievance

Date

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* 7. Location

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* 8. Reason for Complaint

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* 9. Please describe the event(s) that led you to file a complaint

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