Black Oxygen Information Gathering
The purpose of this form is to gather information to assess potential claims you may have involving the purchase and/or use of Black Oxygen products.  All information will be held confidential and privileged.  However, completing this form will does not create an attorney-client.  A separate engagement agreement is required to establish an attorney-client relationship.
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First Name
Last Name
Email Address
Mailing Address
Phone Number
Role
If a Brand Partner, What Was Your Highest Title?
If a Brand Partner, what was your member name/ID?
Have You Requested That Black Oxygen Accept the Return of Your Unsold Product and Issue a Complete Refund?
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How much Black Oxygen product do you currently have that you are unable to return for a full refund?  If known, please provide the total dollar amount.
Other than the cost of inventory, have you incurred any other monetary damages related to Black Oxygen products?  If so, explain:
Have you, or a family member experienced serious health problems that may be attributed to the use of Black Oxygen?  If so, explain:
Please provide additional information that you would like for us to know in evaluating these claims.
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