(please fill-out to the best of your ability)

CONSUMER INFORMATION

Name

Address

Phone

E-mail

Fax

COMPANY INFORMATION

Company Name

Address

Phone

E-mail

Fax

Web site

Person who you have contacted, if Known

COMPLAINT INFORMATION

Provide a copy of your letter, e-mail, etc. that you sent to the company.


Provide a copy of any responses from the company.


Provide a copy of any relevant supporting documentation.


Please describe your data privacy complaint including any relevant facts.


Please let us know what resolution you are seeking.