Bury Council

Your Voice Counts

Customer Details

If you would like a personal reply, please provide the following details.
If you would like a response through e-mail please provide your e-mail address:

Firstname:

Surname:

Address:

Post Code:

Telephone Number:

E-Mail:

Your Comments

Please give details of the complaint, compliment or suggestion in the space provided.

This is a:

Comments: please give as much information as possible such as When? Where? Who?

If a complaint is being made, what action do you feel should be taken to resolve it?

Confidential Monitoring

You do not have to fill in this part of the form.
We are requesting this information to help us make sure we are providing a fair and equal service to everyone.

Your Age:

Are you:

Do you have a long standing illness that limits your daily activities in any way?

Which religion or belief do you follow?

Other Religion:

If English is not your main language, which language would you like us to :

speak to you in ?

write to you in ?

Ethnicity:

If you selected any 'Other' from the list, please give details

Is there anyone who relies on you for care and attention because of long-term physical or mental ill-health or disability, or problems relating to old age? (Do not count anything you do as part of your paid work.)

Yes No