Dispute Form

Dispute Form:
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Your Full Names

PrefixFirst NameMiddle NameLast Name
Address

Street Address

Suburb

CityState / Province

P.O. Box (box number, suburb/city)Country
P.O Box

P.O. Box Number

Suburb

CityState / Province

Country
Phone Number

Area CodePhone Number
E-mail
example: mediationnamibia@gmail.com
The details of the (other person) with whom you have the dispute

PrefixFirst NameMiddle NameLast Name
Address (other person)

Street Address

Suburb

CityState / Province

P.O. Box (box number, suburb/city)Country
P.O Box (other person)

P.O. Box Number

Suburb

CityState / Province

Country
Phone Number (other person)

Area CodePhone Number
E-mail (other person)
example: mediationnamibia@gmail.com
How did you hear about us?
Other
Details of dispute:
When, where, who present, what is the dispute, why do he/she owe you. how did it happen?
Suggestions to resolve dispute
Do you want to commence with?
Select you mediator/arbitrator
view profile of possible mediators/arbitrators at http://www.mediationnamibia.com/mediators

Attach contract (if applicable)

Browse Files
contract/agreement [max file size 10 MB] Cancelof
Attach proof of payment (admin fee only - N$500)

Browse Files
PJ Swanepoel, Bank Windhoek., Branch Maerua Mall 483-872, Cheque Account 8003095022 (Ref: mediate + your name) Cancelof
Date for mediation/arbitration (14 days from today)
Should be Empty:

Dispute Form: