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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