Nature of Infringement: ____ Copyright ____ Trademark
Description of your proprietary material that has been infringed:
Registration numbers of your proprietary material:
Description of infringing material located on our website:
URL of Action Number on website at which infringing material is located:
Contact Information at which you can be reached:
Name: ___________________________________________________________________
Address: _________________________________________________________________
City/State/Zip _____________________________________________________________
Telephone ____________________________ Fax ________________________
E-mail Address ___________________________
By signing below, you certify, under penalty of perjury under the laws of the United States of America, that (1) you are either the rights holder, or authorized to act on the right holder's behalf, (2) you have a good faith belief that the use of the allegedly infringing material has not been authorized, and (3) the information provided above is true and accurate.
Signature: __________________________ Date: ________________________
Name: __________________________
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