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(if you would like a Word version of this document e-mailed to you, please send your request to info@bristolmediation.com) REQUEST FOR MEDIATION 1. Person/Entity Requesting Mediation: Name_________________________________________________________________ Company______________________________________________________________ Address____________________________________________Unit/Suite No.________ City_________________________State_________________________Zip__________ Phone_________________Cell_________________________Fax_________________ E-mail address___________________________________________________________ Legal Counsel or other Representative: Name__________________________________________________________________ Firm____________________________________________________________________ Address_____________________________________________Unit/Suite No.________ City_________________________State_________________________Zip___________ Phone_________________Cell_________________________Fax__________________ E-mail address____________________________________________________________ 2. Person/Entity You Wish To Mediate With: Name_________________________________________________________________ Company______________________________________________________________ Address________________________________________________Unit No.________ City_________________________State_________________________Zip__________ Phone_________________Cell_________________________Fax_________________ E-mail address____________________________________________________________ Person/Entity’s Legal Counsel or other Representative: Name __________________________________________________________________ Firm____________________________________________________________________ Address_____________________________________________Unit/Suite No.________ City_________________________State_________________________Zip___________ Phone_________________Cell_________________________Fax__________________ E-mail address____________________________________________________________ 3. Brief Description of Dispute (please explain the specific issues in dispute as clearly as possible): ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 4. Have any formal court or arbitration pleadings been filed in connection with this dispute? Yes_____No_____ If yes, have any hearings or trial dates been scheduled, and are there any time limitations involved? Yes_____No_____ Hearing Date__________ Court Case # Judge ___________ Other ________________________________________________ Time Limitation(s) _______________________________________________________ 5. Do you have the authority to enter into and sign a binding written agreement on behalf of yourself or the party you represent in the dispute? Yes_____No_____ Comment:_______________________________________________________________ ________________________________________________________________________ 6. Please provide alternative days when you will be available for mediation: ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ 7. Please provide the desired outcome you would like to see at mediation: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ I understand that each party to the dispute must agree to mediation and sign an agreement to mediate and a confidentiality agreement before the party may participate in the mediation. I also understand and agree that I am responsible for my portion of the mediation fees incurred in connection with the services provided by Bristol Mediation Services. Your Name: ________________________________________________________ Signature________________________________________________________________ Company:_______________________________________________________________ Date:__________________________________________________________________ Please fax this form to (661) 252-2566 or mail the form to Bristol Mediation Services, [INFO BELOW THIS LINE FOR INTERNAL USE ONLY] Case No.:___________________________ Mediation Date:_______________________ |
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