American Stock Exchange - Regulation - Investor Complaint Form


Investor Complaint Form

All complaint information will be treated in confidence to the fullest extent possible. However, FINRA Market Regulation - Amex Division cannot guarantee that during the course of a related investigation or possible prosecution of the matter that the source of the complaint will not become known. To submit an anonymous complaint, choose "Yes" below. Submitting an anonymous complaint will prevent FINRA Market Regulation - Amex Division from following up to gather additional details. (Bold red text indicates required fields/questions.)

Contact Information

Do you wish to make an anonymous complaint? Yes No

First Name	Middle Name	Last Name
Name of Company (optional)
Address 1
Address 2
City	State	Zip Code
Province	Country
Work Phone	Fax
Home Phone	Email

Trade Complaint

Are you able to provide details of a specific trade? (Example) Yes No

Security Type		Other
Security Name		Security Symbol
Quantity	Execution Price	Buy/Sell	Trade Date (MM/DD/yyyy)
Order Entry Time : :		Order Execution Time : :
(h) (m) (s)		(h) (m) (s)
Brokerage/Specialist Firm

For options transactions, include the following information:

Option Symbol

Strike

Series

Call/Put

The FINRA Market Regulation - Amex Division would like to gather as much detail as possible about the complaint. Please describe the nature of the complaint including the type of problem being reporting. (For example, if it is believed there is an instance of insider trading, describe the situation and provide as much specific detail and evidence as possible.)

Summarize the complaint : (1500 Character Limit)

Supporting Documentation and Other Regulatory Contacts

Indicate which documentation, if any, can be provided regarding this complaint:

Check all that apply.

None

Trade Confirmation

Monthly Account Statement

Correspondence To and From Firm

Notes of Conversations with Firm

Other

Send supporting documentation to:

FINRA Market Regulation - Amex Division
One Liberty Plaza
52nd Floor
New York, NY 10006
Fax: 212-306-1896

Have you complained to the brokerage firm? Yes No

If available, provide the following information.
Additional details will be requested during the complaint process, if necessary.

Date of Contact
Name of Contact
Status/Resolution
Reference Number
(if available)

If resolved, describe how: (100 Character Limit)

Have you contacted any other regulators? Yes No

Check all that apply.

Securities and Exchange Commission (SEC)

State Regulator
Please select state(s)

Commodity Futures Trading Commission (CFTC)

FINRA Market Regulation - NYSE Division

Securities Investor Protection Corporation (SIPC)

Other(s)

Have you filed an arbitration claim? Yes No

Check all that apply. If available, provide the following information:
Additional details will be requested during the complaint process, if necessary.

Organization Date of Contact Name Contact Status/Resolution Reference Number
(if available)

FINRA

FINRA Market Regulation - NYSE Division

American Arbitration Association

Other


None
Trade Confirmation
Monthly Account Statement
Correspondence To and From Firm
Notes of Conversations with Firm
Other

Date of Contact	Name of Contact	Status/Resolution	Reference Number (if available)
If resolved, describe how: (100 Character Limit)


Securities and Exchange Commission (SEC)
State Regulator Please select state(s)
Commodity Futures Trading Commission (CFTC)
FINRA Market Regulation - NYSE Division
Securities Investor Protection Corporation (SIPC)
Other(s)

Organization		Date of Contact	Name Contact	Status/Resolution	Reference Number (if available)
Check all that apply.		If available, provide the following information: Additional details will be requested during the complaint process, if necessary.

FINRA
FINRA Market Regulation - NYSE Division
American Arbitration Association
Other