National IPR Coordination Center
Complaint Referral Form
I. Complaint Information:
Date of Complaint:
(MM/DD/YY)
*First Name:
*Last Name:
Home Phone:
Home E-Mail:
Street Address:
(Line 1)
(Line 2)
Suite/Apt:
City:
State:
Zip Code:
*Company:
Title:
*Work Phone:
Work E-mail:
*Street Address:
(Line 1)
(Line 2)
*City:
*State:
*Zip Code:
*Country:
Please list the easiest way and most convenient time to contact you.
*What is your trademark name? Describe your product.
*Is the trademark registered with the U.S. Patent and Trademark Office, U.S. Department of Commerce?
YES NO If yes, please provide the registration number Trademark Number:
*Is the trademark recorded with U.S. Customs and Border Protection (CBP)?
YES NO If yes, please provide the recordation number. (To record your trademark with CBP, please contact CBP, IPR Branch at (202) 344-2410) Recordation Number:
II. Violator Information:
Who are you filing this complaint against?
Business/Company Individual Both
Information about Business/Company
*Business/Company Name:
Work Phone:
E-mail:
*Website URL:
Handle (IRC/ICQ):
Server:
IP Address:
Website/FTP:
Password:
*Street Address:
(Line 1) (Line 2)
*City:
*State:
*Zip Code:
*Country:
Are you involved in any litigation/claims against this business/company?
YES NO
More Details:
Information about the Individual
*FirstName:
*Middle Name:
*Last Name:
Date of Birth:
(MM/DD/YY)
*SSN:
*Gender:
Male Female
Home Phone:
Work Phone:
E-mail:
*Website URL:
Handle (IRC/ICQ):
Server:
IP Address:
Website/FTP:
Password:
*Street Address:
(Line 1) (Line 2)
*City:
*State:
*Zip Code:
*Country:
Are you involved in any litigation/claims against this individual?
YES NO
III. Violation:
Type of infringement:
Copyright Trademark
*What is the suspected infringing merchandise / commodity?
*Why do you suspect the merchandise / commodity is counterfeit?
Do you have a sample of the infringing item?
YES NO
What is the country of origin of the suspected infringing merchandise?
From what city, state, and/or country is the suspected infringing merchandise being distributed? Who is distributing the suspected infringing merchandise?
*Provide the names/addresses of the importers involved.
*Provide the names/addresses the foreign manufacturers.
Does the infringing merchandise present potential health and safety issues(e.g.: exploding parts, fire hazards, counterfeit medications or aircraft parts)?
YES NO
Have you previously referred this information to any law enforcement or government agency?
