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Please note that all fields marked with * are required.
When you have filled in all the required fields, please click the submit button at the bottom of the form to submit your registration.
Title * please select Dr Hon Leut Lord Madam Major Master Mesdames Messrs Miss Mr Mrs Ms Pastor Private Prof Rev Sgt Sir
Gender * please select Male Female
First name *
Middle name
Last name *
Are you making the allegation on behalf of someone else?
Yes
No
Are you making the allegation on behalf of a business?
Business name
Is the business incorporated (eg. Pty Ltd company)?
ACN
Address line 1 *
Address line 2
City *
Postcode *
Country *
State *
Email address *
Verify Email address *
Telephone home * (at least 1 phone number is required) ( )
Telephone work * ( )
Telephone mobile *
Fax ( )
Name of financial services provider *
If the allegation concerns an account, what name(s) is the account held in?
Type of financial service *eg. home loan, credit card, transaction account
Account number
When did the events causing the alleged breach first occur? *
Date the account holder first became aware of the alleged breach *
Date the account holder first reported the alleged breach with the financial service provider
How did you raise your concern with the financial services provider? *
In writing
In person
By telephone
Other
What department or person did the account holder report the allegation to?
Financial service provider's reference number
Short description of the allegation *
Please provide details of the allegation, including an explanation of why the account holder is not satisfied with any response received from the financial services provider *
What do you think is a fair and reasonable resolution to the matter? *
Please provide all supporting documents (e.g. copies of correspondence, account statements, loan or policy documents). It is important that we receive a copy of any response from the financial service provider in relation to the alleged breach.
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Add another file.
If you are unable to provide your supporting documents electronically, please send them to us by post (PO BOX 14240, Melbourne, VIC, 8001) or fax (03 9613 7481) and quote your case number.
A concern can be lodged with the Committee at any time although we may not be able look at something while it is being considered by another forum including a Court. It is helpful for us to know who else may be dealing, or have dealt, with your concern and what that outcome was, so please answer the questions below. For further information regarding when we may or may not consider an allegd breach of the Code - refer to the Constitution
Has the alleged breach been considered by, or is currently being considered by:
ASIC
Credit Ombudsman Service (COSL)
Financial Ombudsman Service (FOS)
Financial Service Provider
If you ticked any of the above, what was the outcome?
Is there any current Court action relevant to your matter?
Our privacy policy sets out our commitment to your privacy. In order to investigate your concern we need your authority to exchange information with the financial service provider about your alleged breach.
I/We authorise CCC to send the information provided to my financial services provider.
I/We have read and understood the privacy statement
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