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Name and Address of Consumer









Is Consumer expected to be out of the Island anytime soon? :

Name and Address of Supplier








Is Supplier a register business?:
Is Supplier trading a business?:

DETAILS OF GOODS/SERVICES


Please select the detail: GoodsServices





Payment Terms:


Terms Of Contract:

Have You Discussed Your Complaint With The Supplier?:


Title:

Did The Consumer Request Supplier To Remedy The Breach?:
Redress Claimed:



Did you request supplier to remedy the breach?:

Signature