NCDOJ

Telemarketing Complaint Form

Please print a copy of your completed form to mail in with any supporting documents and a copy for your records. Please note that the printed copy may not include all of the information included in the details of complaint box.

Prefix:
* First Name:
Middle Name:
* Last Name:
Suffix:
* Address:
* City:
* State:		* Zip Code:
* Day Phone:	() -Second partThird part	Ext:
EveningPhone:	() -Second partThird part	Cell Phone:	() -Second partThird part
* Email:
Age:		Gender:
I am a military service member or military spouse:		No Yes

Prefix:
First Name:
Middle Name:
Last Name:
Home Phone:	() -Second partThird part	Business Phone:	() -Second partThird part
Relationship to Victim:

* Company Name:
AboutFName:
Last Name:
Address:
City:
State (or Canadian Province):
Zip Code:
Country:
* Phone Number:	() -Second partThird part
Additional Phone Number(s): (ex. 919-555-1212; 919-555-1234 with the numbers separated by semi-colons)
Fax:	() -Second partThird part
Email:
Website:

Date of First Call:	Date and time	Time of First Call:
Date of Last Call:	Date and time	Time of Last Call:


Was the call a prerecorded message?:
What was the number that appeared on Caller ID? (if available):	() -Second partThird part
Was the Caller ID blocked by the telemarketer?:	No Yes
Did you receive the call or did you call the company?:	Received Call Made Call
What product or service, if any, was offered?:
Did the caller say you had won money or a prize?:	No Yes
Did the caller claim to be a relative?:	No Yes
How much did the caller ask you to pay?:
Did you give the caller money or authorize payment?:	No Yes
If yes, was payment by:
Amount Paid or Lost?:
Is the caller continuing to communicate with you?:
Is your phone number in the Do Not Call Registry?:	No Yes
Have you made specific requests not to be called again?:	No Yes
If yes, provide dates of request:

Telemarketing Complaint Form

Consumer's Information

Reporting Party Information (if different from Consumer)

Company or Person You Are Complaining About

Tell Us About Your Complaint