Arizona Attorney General: Antitrust Unit
Gasoline Price Complaint Form
Consumer's Information
First Name:
[required]
Last Name:
[required]
Address:
City:
State:
Zip:
Phone:
e-mail address:
Gasoline Station's Information
Name:
[required]
Address:
[required]
City:
[required]
State:
Zip:
Phone:
(if known)
Details of Purchase
Grade of Gasoline Purchased:
Select Gas Grade
Regular (87)
Mid-grade (89)
Premium (91)
Diesel
Other
[required]
Price per Gallon Paid:
[required]
Total Dollar Amount of Purchase:
Date of Purchase:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2003
2004
2005
2006
2007
2008
2009
2010
[required]
Time of Purchase:
Hour
1
2
3
4
5
6
7
8
9
10
11
12
Minute
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
AM or PM
AM
PM
Comments:
Thank you for taking the time to complete this form.
