Fair Shake Formal Resolution Submission Form

* Required

Company Name *

Location *

Your First Name *

Your Last Name *

Your Email *

Your Cell Number *

Receive text message when the company responds?

Date Of Event *

Issue *

Sub Issue *

Description *

Who Was Involved? (Please provide names and what they did or said, if possible) *

Proposed Resolution *

Would you accept money to resolve this issue? How much? *

Please provide details about your proposed resolution? *

Are you represented by an attorney? *

Are you active duty military? *

Are you currently deployed? *