Fax DNC™ Registry

Information About You:

Fax Information:

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: (500 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: (500 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-NotFax-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: (500 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. (500 Characters Max)

Information For The DNC Registry