NON RECEIPT OF GOODS DISCLAIMER FORM

Customer Name Abel Antonio Ramos Vasquez

Av. Máximo Gómez, No.02 Gazcue

MINERD, Anexo Sur, 3er Piso
Address Distrito Nacional
Distrito Nacional
10205
Dominican Republic

Order Number: 109573998 Date Shipped: 25 November 2017

I confirm that goods I ordered have not been received. I have checked with other members of
my *household/neighbours (*delete as applicable) and confirm that they have not received the goods
either.

I agree to co-operate with the carrier’s security and/or the Police in the event of any
investigation into the missing items.

It is our policy to replace any item that is lost in post and a replacement item will be
sent out in due course. This does not affect your statutory rights.

Comments
When I click track your order, in the web page of the courier it say not found.
The estimated delivery in the web page of my protein says 8-12 december 2017.

Items Not Received

Impact Whey Protein - 5.5lb - Pouch - Unflavored (2 units)
Creatine Monohydrate - 2.2lb - Pouch - Unflavored (1 unit)

I believe the above declaration is true to the best of my knowledge and belief. I understand
to make a false statement could lead to prosecution.

Customer Name: Abel Antonio Ramos Vasquez Signature:

(print)

Claim Ref. No:

(Internal Use Only)