Coin Information Form

Contact Information:

Name:

(required)

E-mail:

Preferred Contact Telephone:

(required)

Address:

(required)

City:

(required)

State:

(required)

Zip:

(required)

Coin Purchase Information

Type of Coins Purchased:

Quantity of Coins Purchased:

What company or companies they were purchased from:

(required)

Amount company charged for the coins:

How many transactions with the company:

Location of coin companies where purchases were made:

Complaints:

	High pressure sales tactics
	Unauthorized charges to your credit card
	Being promised a certain coin and receiving a different one
	Finding out the coin you purchased was not worth what you paid
	Guarantees that your coin would go up in value
	Refusal to buy back or sell your coins as promised when you purchased them
	Receiving coins in the mail you did not order
	Getting the run-around when you call to complain about a purchase
	Other

Additional Comments:

NOTE: By providing us your phone number, you are giving us permission to call you in response to this request, even if this phone number is in the State and or National "Do Not Call Registry".