Dispute Form

Dispute Form:
Date*

DayMonthYear
Date
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?*

MediationArbitration
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: