Complaint Form - Arizona Corporation Commission (Page 3 of 5) in pdf

Complaint Form - Arizona Corporation Commission Page 3

THIS DOCUMENT IS AVAILABLE IN ALTERNATIVE FORMATS BY CONTACTING YVONNE L. McFARLIN, EXECUTIVE

ASSISTANT TO THE EXECUTIVE SECRETARY, VOICE PHONE NUMBER 602-542-3931, E-MAIL YMCFARLIN@CC.STATE.AZ.US

COMPLAINT FORM

)

(PLEASE TYPE OR PRINT IN BLACK INK ONLY

State Name and Address of FIRM or PERSON

State YOUR Name and Address:

Complained Against:

ZIP:

Phone:

Home Phone:

Business Phone:

Name of Stockbroker or Salesperson:

Type of complaint:

Complaint against a Company or Firm

Complaint against an individual

Other, Please specify:

Date of transaction:

Place of Transaction; specify the states in which you and the salesperson were located:

Witnesses to the transaction:

State the type of investment involved (e.g., stock, note, limited partnership, etc. If you are not certain,

describe on last page):

-If you invested in stock or bonds, what was the name of the issuing corporation?

-If you invested in a note, who was the maker (company or individual) responsible for paying it?

-If you invested in a partnership, what was the name of that partnership?

Amount involved in transaction:

Did you sign any papers or documents?

Yes

No (If Yes, please attach copies of them.)

How did you first learn about this investment?

Have you complained to the Company or Firm?

Yes

No If yes, to whom? When?

What was the response?

May we send a copy of your complaint to the firm or individual complained against?

Yes

Does an attorney represent you in this matter?

Yes

If yes, give attorney's name and address:

REV. 1/13/04

Complaint Form - Arizona Corporation Commission Page 3