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Problem Report Form

*(denotes required field)

First Name *

Last Name *

Title *

Company/Location *

Address 1 *

Address 2

City *

Country *

State *

Zip/Postal Code *

Phone *

Fax

E-Mail *

Type of Operation *

Product Information

Product Code

Example: 03033 (French Bread Dough)

Description of Product *

Product Code Date (on case) *

Examples:
15034208A 00:37 USE BY 04/23/05
C711 4 208F 17:07 EXP: APR 23, 2005

Expiration Date (on case) *

Number of Cases

Customer #/Sold-To #

Example: 235854 (Sysco Minnesota)

Distributor

Distributor City

Distributor Country

Distributor State

Description of Problem *

Who is experiencing the problem?