Dispute Form

Date *

Date

Your Full Names *

Prefix First Name Middle Name Last Name

Address *

Street Address

Suburb

City

Country

P.O Box *

P.O. Box Number

Suburb

City

Country

Phone Number *

Area Code Phone Number

E-mail

example: mediationnamibia@gmail.com

The details of the (other person) with whom you have the dispute *

Prefix First Name Middle Name Last Name

Address (other person) *

Street Address

Suburb

City

Country

P.O Box (other person) *

P.O. Box Number

Suburb

City

Country

Phone Number (other person) *

Area Code Phone 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? *

Mediation Arbitration

Select you mediator/arbitrator *

view profile of possible mediators/arbitrators at http://www.mediationnamibia.com/mediators

Please enter details of mediator/arbitrator: *

Full Name

Address

Contact Number

Email

1

Attach contract (if applicable)

Browse Files

contract/agreement [max file size 10 MB]

Attach proof of payment (admin fee only - N$500)

PJ Swanepoel, Bank Windhoek., Branch Maerua Mall 483-872, Cheque Account 8003095022 (Ref: mediate + your name)

Date for mediation/arbitration (14 days from today)

Dispute Form: