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Information About You
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*Last Name:
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*First Name:
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Middle Name:
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*Street Address:
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*City:
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*State:
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*Zip:
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*Day Phone:
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Evening Phone:
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*E-Mail Address:
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For our statistics, please select your age group:(optional)
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What is the name of your Internet Service Provider (ISP)?
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Have you notified your ISP regarding this e-mail?
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If YES, what was the provider's response?
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Information About The Sender
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*Business Name:
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*Street Address:
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*City:
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*State:
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*Zip:
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Business Phone:
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Business Fax:
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Toll-Free Number:
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*eMail Address:
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Name of Owner / Manager:
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Names and address of any other businesses involved in your complaint:
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Salesperson's Name:
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Information About The eMail
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We need the complete header information from the e-mail in order to investigate your complaint.
*When you have located the header information, copy and paste the information into this box:
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*Web site referenced in the e-mail:
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Have you notified the sender's ISP's complaint center regarding this email?
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If YES, what was the provider's response?
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*Please enter the deceptive subject line of the e-mail here:
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*Please copy and paste the body of the e-mail here:
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Is the return e-mail address in the header of the message an accurate address for the business?
Note: DO NOT REPLY to the message if you are not sure.
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If you tried to reply to the message, were you successful?
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Does the subject line of the e-mail accurately describe the content?
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Did the sender of the e-mail message use an ISP's address without permission?
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Did the sender of the e-mail have any other way to know your information?
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If YES, how?
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Information For The DNC Registry
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The DNC Registry will periodically issue press releases, consumer warnings and other notifications to the public. We would like to include you in our eMail list for these notifications. Please answer "Yes" in this box, if you want to receive these notifications.
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The DNC Registry may, at our discretion, send your complaint to the business about which you are complaining, unless you answer "NO" in this box. Generally, junk e-mail complaints filed by consumers are not forwarded to senders of junk e-mail by the DNC Registry. However, there are times when this is needed. Accordingly, if you do not wish your information forwarded on, please choose "NO."
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Are you willing to allow your complaint to be made public? If you answer "No," your complaint and related documents will not be disclosed pursuant to requests under the state Public Disclosure Act. The DNC Registry will maintain the complaint for internal purposes only.
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Declaration: By filling in my name and the date below, I declare, under penalty of perjury under the laws of my State within the United States of America that the information contained in this complaint is true and accurate.
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*Signed - Name
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*Declared this date:
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