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ONLINE COMPLAINT REGISTRATION FORM

Please proceed only if the matter does not require urgent attention.

If the matter requires urgent attention & if the Survior is a female then please call 181 or 100.

Please Consider Calling

181

For Women

1098

For Children

15100

For Men, Children & Women

Survivor Gender *

Please explain the problem in brief. *

Survivor Details

What is the name? *

What is the age? *

What is the phone number? *

WhatsApp number - if available?

Email address of - if available?

Is this form being filled by the Survivor himself/herself? *
Yes No

Is this form being filled by the Agency, Which is registered with us?*
Yes No

Name of registered agency

Complainant Details

Name *

Age *

Phone number *

WhatsApp number - if available

Email address *

Incident Location

State name *

District name *

Please enter captcha*

Attachment

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