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Complaint Form

*Required fields are marked with an asterisk.

  1. Information about purchaser or complainant (You)

    Today's Date*

    Name (Last, First, Middle)*

    Home Address*

    Home Phone number*

    Business Phone number

    Email Address

    Are you willing to be interviewed by an investigator from this office?*
    Yes No

    Are you willing to be a witness if formal proceedings are commenced by the Securities Commissioner?*
    Yes No

  2. In what did you purchase or invest? (i.e. common stock, debenture, limited partnership, investment contract).

    a. Type of Security

    Other:

    Number of Shares

    Total Amount Invested*

    Date Purchased

    b. In what company, corporation or association did you invest?*
    (Company Name, Address, Phone Number)

    c. Give information regarding the persons involved in the transaction.
    (i.e. Name, Address, Phone Number)

    d. How were you contacted?

  3. Please provide a brief narrative of the transactions which gave rise to your complaint, including any relevant internet information.*

  4. Have you complained to the subject or seller?*
    Yes No

    If yes, what offer of adjustment or explanation was made?

  5. Any Additional Information

  6. What would you consider to be a satisfactory solution?*



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All Rights Reserved.