Reconsideration Request Form

Title (required)

Author(s): (required)

Publisher (if known):

Request Initiated by: (required)

Telephone: (required)

Address: (required)

City: (required)

Zip: (required)

Is complainant representing self or representing an organization: (required)

Organization's name, if complainant is representing an organization:

Did you read/view/listen to the entire work? (required)

What concerns do you have about this work? Please be specific (i.e. cite pages, timestamps for AV materials, scenes, lyrics, etc.) (required)

What action would you like to see taken regarding this work? (required)

In its place, what work of equal quality would you recommend to convey of the subject treated? (required)

If you have any supporting documents to your claim, upload them in a .pdf format

Your Signature (required)

Confirm e-Signature

Review Electronic Records and Signatures Policy (required)

I agree to use electronic records and signatures

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