Counterfeit Product Complaint
Person Making the Complaint
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Description of Item/Company About Which You Are Complaining
Name/Description of the Item Involved
*
Name of Trademark You Believe is Being Counterfeited
*
Is the Item Being Sold Online? If So, Name of Website
Description of Place Where Item is Being Sold
Company Name
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Website Address
Other Details
How Did You Find Out This Item Was For Sale?
Do You Have A Sample of the Item For Inspection By This Agency
Submit
Should be Empty: