Complaint Form

Name

Name of the Complainant (Person, Firm or Institution)

Address

Phone No.

Fax No.

City/County/State

Country

Name

Address

Phone No.

Fax No.

Name

What is the name of the Newspaper, Magazine or Website where the material was printed

Date

Date of Publication/ Broadcast

Headline/URL

Headline/URL or any other identification that can help us locate the material

Complaint

Briefly state the nature of your complaint.

Remedies Sought

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