Form for financial services complaints – Request for Mediation

First name and surname:*
Street and house number:*
Postcode and city:*
Your e-mail address:*
Information about the trader/financial
services provider (your complaint is against
a trader/provider who is a legal person):*
The facts that generate the dispute / alleged breaches
– summary of what the complaint is about:*
Proposed evidence on which your
complaint is grounded (attachments):*
The complaint is being considered by
another dispute resolution body, an
administrative body or by a court:*
yes
no
Stating possible grounds on which a motion
to exclude a mediator in the dispute is based:
Your request
(expected solution for the dispute resolution):
 

The fields with * are mandatory.