Your Name:

Email Address:

CHECtravel Number:

Your Home Exchange Club:

Who do you want to mediate with (Name)?

Exchanger CHECtravel Number:

Exchanger Email Address:

Exchanger Home Exchange Club:

When did the incident in question occur (MM/YY)?

Have you notified the offending party?
Yes
No

Have you attempted to resolve the problem with this individual?
Yes
No

Nature of the Problem: