Product Exception Report

Reporting Agency Name(Required)

Please enter you Agency name

Agency ID(Required)

Please enter you Agency ID number

Date(Required)

Product Name(Required)

Product Description(Required)

Quantity (Cases or Individual Packages or Cans)(Required)

Reporting Issue, please check all that apply:(Required)

Spoiled

Expired

Damaged

Use By/Best By/Expiration Date:

Received Date

Reason for damaged (weather, pest, dropped, etc.)

File

Max. file size: 256 MB.

Signature

Date