Suggerimenti e reclami

Il sottoscritto/a ________________________________________________________________

nato a __________________________________ il___________________________________

residente in ___________________________________________________________________

tel. ____________________ fax ____________________ e-mail ________________________

       Suggerisce:

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

       Inoltra reclamo per la seguente motivazione:

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

       Richiede un incontro con ________________________________________________________

Per la seguente motivazione: __________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Il sottoscritto ___________________________________________________________
presta il suo consenso al trattamento dei dati personali ai sensi dell’art. 13 D. L.vo 196/2003.

       Do il consenso

       Nego il consenso

Data                                           Firma