Your Company Name:
Date and Time of the promotion or practice:
Did you see the Ad Choices icon:
Type of device the online ad was seen on (computer, smartphone, iPAD, etc):
Where you saw the Ad (website address):
Who sent the ad? Information about the ad (sponsoring company, product or service promoting):
Your internet browser (Internet Explorer, Chrome, Firefox...):
Your Internet Service Provider -- ISP (Yahoo!, AOL, AT&T, Microsoft, etc.):
Have you contacted your Internet Service Provider?
Have you contacted the company serving the Ad?
Any contact information for ISP or Ad company (person, phone, email and address of the organization):
The response from the company and/or ISP:
Did the opt-out process work at all, temporarily, never?
If applicable, the type of error opt-out message received:
Please pick category of concern, you may select more than one:
Placement of online ad (blocking content)
Content/nature of online ad (offensive)
Content/nature of online ad (political)
Targeted Ad did not match your interests
Please give a brief overview of your concerns and attach any relevant correspondence or other documents demonstrating lack of compliance such as: email correspondence; a screenshot of the OBA advertisment; a copy of your opt-out confirmation; or other materials relevant to the transaction:
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