Form under Rule 6(2)

A. Complaint

1. Name of the complainant : __________________________
(Person who has sent the complaint to the Ministry/Department/State Govt./Nodal Officer)

2. Address : _____________________________________________________
_____________________________________________________
City________________ Pin Code:_________________

3. Telephone : _____________ (prefix STD code)

4. Fax (if any) : _____________________________________

5. Mobile (if any) : ___________________________________

6. Email (if any) : ____________________________________

B. Detail of website /Computer resource / intermediary/ offending information hosted on the website (please give detail wherever known)

7. URL/ Web address:_______________________________

8. IP Address:_______________________________________

9. Hyperlink: _______________________________________

10. Server/Proxy Server Address: _______________________

11. Name of the intermediary: __________________________

12. URL of the intermediary: ___________________________
(please attach screenshot/printout of the offending information)

13. Address or location of intermediary in case the intermediary is telecom service provider, network service provider, internet service provider, web-hosting provider and cyber café or other form of intermediary for which information under points (7), (8), (8), (9), (10), (11) and (12) are not available.
_____________________________________
_____________________________________
_____________________________________

C. Detail of Request for blocking

14. Recommendation/Comment of the Ministry/State Govt. ___________________________________________________________
___________________________________________________________
___________________________________________________________

15. The level at which the comment/recommendation have been approved (please specify designation): ________________________

16. Have the complaint been examined in Ministry/State Government: Yes/No

17. If yes, under which of the following reason it falls (please tick):
(i) Interest of Sovereignty or integrity of India
(ii) Defence of India
(iii) Security of the State
(iv) Friendly relations with foreign States
(v) Public order
(vi) for preventing intermediary to the commission of any cognizable offence relating to above.

D. Detail of the Nodal Officer forwarding the complaint along with recommendation of the Ministry/State Govt. and related enclosures

18. Name of the Nodal Officer:_________________________

19. Designation:_____________________________________

20. Organisation: _____________________________________

21. Address:_________________________________________
________________________________________
________________________________________ City: _____________ Pin Code:____________________

22. Telephone: ________________ (prefix STD Code)

23. Fax (if any): _______________________

24. Mobile (if any): ____________________

25. email (if any): __________________________________

E. Any other information:

F. Enclosures:

1.
2.
3.

Date:
Place:
Signature