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Tell Us About Yourself

	* You must complete this information.
Title
* First name
Middle initial
* Last name
* Street address
* City
* State/Province (required if US or Canada)
* Zip/Postal code
* Country
Daytime phone
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Fax
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Tell Us About the Company or Individual You Have a Complaint Against

Company name
Street address
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State/Province
Zip/Postal code
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Describe Your Complaint

* Please tell us about your complaint with as much detail as possible. Please include the name of the company, the date of your purchase, and the total amount you spent. Please describe any conversations you have had up to this point with representatives of the company.

Questions? Comments? Email Us At: info@consumer-advocacy.org

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