DNC Registry™

Information About You:   Necessary for All Forms of Complaints

Call Recipient:   Telephone number where you received the call/message(s).

( ) -

Date/Time :   When did you receive the call(s)?

Date:  /   /    Time:  :  AM PM

Date:  /   /    Time:  :  AM PM

Date:  /   /    Time:  :  AM PM

Date:  /   /    Time:  :  AM PM

Caller ID Information:   Use for Telemarketing, Junk-Faxes and (Cellular) SMS Text Message Spam

Did you receive caller ID information for the call(s) in question? Select Yes No Don't have caller ID

Information obtained through caller ID:  ( ) -

Business name:

Did the caller ID information accurately report the name and/or calling number for the call in question?  Select Yes No Not certain

How did you determine it was not accurate? (1000 Characters Max)

Call Information:   Use for Telemarketing and (Cellular) SMS Text Message Spam

Prior Express Consent:

Did you or anyone at your facility give prior express consent for the call(s) to be made?
Select Yes No

Type Of Call(s):

Live (Voice) Call
Prerecorded Message
Text Message
Commercial eMail Message
"Dead Air" or Automated Tones
None of the Above

Describe Call: (1000 Characters Max)

During the call/message;

Was the following information provided?

Name of the business, individual or other entity responsible for the call/message:
Select No Yes

Name(s) provided:

Was this provided at the beginning of the call/message?
Select No Yes

Business telephone number for the entity responsible for the call/message:
Select No Yes

Number(s) provided:

( ) -

( ) -

Other information provided:

Did you listen to the entire call/message?
Select No Yes

Emergency Purpose:

Did the call/message indicate any emergency purpose (a necessary communication in any situation affecting the health and safety of consumers)?
Select Yes No

Describe the Emergency: (1000 Characters Max)

Prerecorded Message - Line Seizure:

Did any message disconnect promptly (within about 5 seconds) after you hung up?
Select Yes No Not certain

Describe: (1000 Characters Max)

Fax Information:   Use for Junk-Faxes

Fax Number:   Telephone number where you received the fax.

( ) -

Date/Time :   When did you receive the fax?

Date:  /   /    Time:  :  AM PM

Required Fax Information:

Is the following information contained either on the first page of the fax or in a margin at the top or bottom of each page.

Date of transmission:  Select No Yes

Name of sender:   Select No Yes   Name:  

Telephone number of sender or number of sending machine:   Select No Yes  Number: (   ) -

Type Of Fax:

Did the fax advertise the commercial availability or quality of any property, goods, or services? Select No Yes

What property, goods, or services does the fax promote?
 Hot stocks  Cheap vacations  Low-interest mortgages  Low cost health care  Other

Other Explained: (1000 Characters Max)

Identifying Information:

Is any information (e.g., addresses, e-mail, websites) provided on the fax to identify the fax sender?

Select No Information Listed Yes

Phone Numbers of Sender:

(  ) -
(  ) -
(  ) -

Business Name of Sender:

Other Information: (1000 Characters Max)

Opt-Out Notice:

Does the fax include an opt-out notice (containing a telephone number, website, or email address) that provides an opportunity to request that no future faxes be sent?

Select No Yes

Opt-out telephone number: (  ) -

Website address to transmit a do-not-fax request:  

E-mail address to transmit a do-not-fax request:  

Is the opt-out notice on the first page of the fax advertisement? Select No Yes

Other Identical Faxes :   Record any other faxes which contain identical information (except for date/time stamp) from this fax sender:

Date:  /   /    Time:  :  AM PM

Date:  /   /    Time:  :  AM PM

Date:  /   /    Time:  :  AM PM

Date:  /   /    Time:  :  AM PM

Established Business Relationship:

Have you or anyone else in your household or business:

(A) - Done any business with the fax advertiser or involving the advertised property, goods, or services (a purchase or other transaction)?
Select No Yes   When? / /

(B) - Made an inquiry or application to the fax advertiser or involving the advertised property, goods, or services?
Select No Yes   When? / /

(C) - If you answered YES to either (A) or (B): Have you taken any of the following actions to make your fax number available to the sender? (check all that apply)
Provided it directly to the sender in connection with a purchase, other transaction, inquiry, or application?
placed it in your own directory, advertisement, or website?
voluntarily placed it in someone else's publicly-available directory, advertisement, or website?
None of the above

Prior Express Permission:

Have you or anyone else in your household or business given the fax advertiser or anyone associated with the advertised property, goods, or services permission to fax an advertisement to you?
Select No Yes

Do-Not-Fax Request:

Have you or anyone else in your household or business asked the fax advertiser or anyone associated with the advertised property, goods, or services NOT to fax an advertisement to you? Select Yes No

(Provide as much detail as possible)

When?   Date: / /

How did you make your request?

  By telephone to (   ) -

  By email to  

  By website request at:  

  Other Describe: (1000 Characters Max)

Describe any response from, or other contact with, the fax advertiser or telemarketer including any difficulty in making your do-not-fax request, or any telemarketing faxes that you received from this advertiser after making your do-not-fax request. (1000 Characters Max)

Information About The Sender   Use for eMail Spam and Junk-Mail

Information About The eMail   Use for eMail Spam

Information About The Mail:   Use for Junk-Mail

Information For The DNC Registry   Use for Your Preferences