Complaint Form
UNLAWFUL INFORMATION REPORT (hereafter: “UIR”)
CHAPTER 1 GENERAL INFORMATION
1. Requestor
- Name
_______________________________________________________________________________________________
- Address
_______________________________________________________________________________________________
- Company*
_______________________________________________________________________________________________
- Telephone number
_______________________________________________________________________________________________
- E-mail address
_______________________________________________________________________________________________
hereafter to be referred to as: “requestor”,
requests that Africa Interactive ceases to transmit the alleged unlawful information and/or removes the alleged unlawful information (hereafter “information”), at Africa Interactive’s discretion, and/or will provide the name, address and residence of the publisher of the information as soon as possible by means of this UIR, of which the nature is clarified below.
*this field is only to be completed if a person submits a request on behalf of a company.
2. What is the location of the information? Add items of proof in this UIR.
_________________________________________________________________________________________________
3. At what moment (time and date) did you discover the information?
_______________________________________________________________________________________
4. The information concerns:
0 child porn [go to Chapter 2]
0 discrimination [go to Chapter 2]
0 defamation, slander [go to Chapter 3]
0 breach of trade secrets [go to Chapter 3]
0 violation of intellectual property rights
or unfair competition [go to Chapter 4]
0 “other unlawful information”, namely: [go to Chapter 3]
______________________________________________________________________________
CHAPTER 2 CHILD PORN AND DISCRIMINATION REPORT
5. Provide a description of the information:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
6. Why, in your opinion, is the information unlawful?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Go to Chapter 5
CHAPTER 3 REPORT OF DEFAMATION, SLANDER, BREACHES OF TRADE SECRETS, ETC.
7. Provide a description of the information:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
8. Why, in your opinion, is the information unlawful? If possible, attach items of evidence to substantiate this.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
9. With respect to whom is this information unlawful?
Name:___________________________________________________________________________________________
Address: _________________________________________________________________________________________________
10. What damage is suffered by the information?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Go to Chapter 5
CHAPTER 4 VIOLATION OF INTELLECTUAL PROPERTY RIGHTS REPORT
11. Which right is violated?
0 Infringement of copyright
0 Infringement of trademark rights
0 Infringement of trade name rights
0 Infringement of patent right
0 Infringement of database right
0 Violation of another right of intellectual property, more specifically:
_________________________________________________________________________________________________
0 In violation of competition law
12. Provide a short description of the information:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
13. Why, in your opinion, is the information unlawful? Attach items of evidence to substantiate this.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
14. Provide the information of the entitled party of the intellectual property rights concerned:
Entitled party’s name:
_________________________________________________________________________________________________
Entitled party’s address:
_________________________________________________________________________________________________
15. What damage is suffered by the information?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
16. Provide a short description of the items of evidence to substantiate the fact that the abovementioned is the entitled party of the intellectual property rights and attach these items of evidence to this request:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
17. Are the requester and the entitled party one and the same person and/or company?
0 Yes [go to Chapter 5]
0 No [go to point 17a]
17a. Provide a short description of the items of evidence to substantiate the fact that the requester was requested by the entitled party to represent their interests in this matter, and attach these items of evidence to this request:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Go to Chapter 5
CHAPTER 5 INFORMATION CONCERNING THE PUBLISHER OF THE UNLAWFUL INFORMATION
18. Is the name and/or address of the publisher of the information known?
0 Yes [go to point 18a]
0 No [go to Chapter 6]
18a. Provide the information of the publisher of the information:
Name:
_________________________________________________________________________________________________
Address:
_________________________________________________________________________________________________
E-mail address:
_________________________________________________________________________________________________
19. Has the requester approached the publisher of the information with the request to remove the information?
0 Yes [go to point 19a]
0 No [go to Chapter 6]
19a. In what manner has the requester approached the publisher of the information with the request/warning to remove the information?
0 By e-mail
0 By telephone
0 By letter
0 By fax
0 By summons [go to point 19c]
0 Other, to wit,
_________________________________________________________________________________________________
19b. Provide a short description of the items of evidence to substantiate the fact that the requester has approached the publisher and attach these items of evidence to this UIR (including any possible answer by the publisher):
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Go to Chapter 6
19c. Provide a short description of the documents of the case which have been in the procedure up to the moment of the UIR, including a possible judgment, and attach copies of these documents to this UIR:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Go to Chapter 6
CHAPTER 6 REQUEST TO DISCLOSE NAME, ADDRESS AND RESIDENCE OF THE PUBLISHER OF THE UNLAWFUL INFORMATION
20. Do you wish to request for the disclosure of the name, address and residence of the publisher of the alleged unlawful information?
0 Yes [go to point 21a]
0 No [go to Chapter 7]
21a. Wy, in your opnion, is the information unlawful? If possible, attach items of evidence to substantiate this.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
21b. With respect to whom is the information unlawful?
Name:___________________________________________________________________________________________
Address: _________________________________________________________________________________________________
21c. What damage is suffered by the information?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
22. Why is it nessesary that the name, address and residence of the publisher of the information will be provided to you?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
23. Is there any other possibility available to obtain the name, address and residence of the publisher of the information?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
CHAPTER 7 MISCELLANEOUS
After receiving the UIR, Africa Interactive shall forward it to the person and/or company responsible for the unlawful information the UIR is related to (hereafter to be referred to as: “person responsible”). The person responsible then has the opportunity to respond to this UIR. If the person responsible has not (fully) reacted within 5 (five) working days, Africa Interactive shall deem itself entitled to cease the transmission of the unlawful information and/or remove the unlawful information and/or to disclose the name, address and residence of the publisher of the information, provided that Africa Interactive has no reason whatsoever to doubt the correctness of the requester’s UIR. Africa Interactive shall retain the right not to comply with the request.
With regard to a request to disclose personal data of the publisher of information, Africa Interactive shall weigh up the interest of the parties involved. Africa Interactive reserves the right not to comply with a request to disclose personal data of the publisher of the information in the event the request is made more than three months after the moment that the information was discovered by the requester. Africa Interactive reserves the right to not (fully) comply with a request to disclose personal data of the publisher of the information in the event Africa Interactive does not (or no longer) have the requested data at its disposal.
By filling in this UIR the requester agrees to indemnifiy Africa Interactive as well as its management, managing directors, employees, representatives, and successors in title against any claims of third parties relating to a blocking of the information concerned or the disclosure of personal data of the publisher of the information. The indemnification also relates to any damages and charges Africa Interactive suffers, will possibly suffer in the future, or Africa Interactive is forced to incur relating to such a claim.
The requester agrees with the “UIR conditions”.
Truthfully, correctly, and fully completed,
In:______________________________________________________________________________________________
Date:____________________________________________________________________________________________
Signature:________________________________________________________________________________________
This UIR is to be sent to the following address:
Africa Interactive
Jansweg 42-E
2011 KN Haarlem
info@africa-interactive.net
+31 (0)23 5315040
