Mediation Request Form Date MM DD YYYY 1. Personal information Name * First Name Last Name Subject * Message * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Email * 2.Party Information Name of Other Party/Parties First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Email 3. Dispute Information Brief Description of the Dispute: Date When the Dispute Arose: MM DD YYYY Location of the Dispute: 4. Mediation Details Have you attempted to resolve the dispute through other means? If yes, please describe: Why do you believe mediation is the appropriate course of action? Preferred Outcome/Resolution: Preferred Dates/Times for Mediation: List 5 5. Additional Information Any additional information that might be helpful for the mediator to know: 6. Acknowledgment and Signature Checkbox * I understand that mediation is confidential and voluntary and that the mediator does not have the authority to make a decision or impose a settlement. I agree to participate in the mediation in good faith and with the intention of resolving the dispute. I have read and agree to be bound by the terms of the payment for mediation services. Thank you!
