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(If you would like a Word version of this form e-mailed to you , please send a request to info@bristolmediation.com)
RESPONSE TO REQUEST FOR MEDIATION 1. Responding Party: Name_________________________________________________________________ Company______________________________________________________________ Address____________________________________________Unit/Suite No.________ City_________________________State_________________________Zip__________ Phone_________________Cell_________________________Fax_________________ E-mail address___________________________________________________________ 2. Legal Counsel or other Representative: Name__________________________________________________________________ Firm____________________________________________________________________ Address_____________________________________________Unit/Suite No.________ City_________________________State_________________________Zip___________ Phone_________________Cell_________________________Fax__________________ E-mail address____________________________________________________________ I agree_________do not agree___________ to mediate my dispute with the person/entity requesting mediation. If you are agreeing to mediation, please complete the information below. If you do not agree to mediate your dispute, please sign and date the bottom of this form and fax or mail it to Bristol Mediation Services at the fax number or address provided. 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 within the next thirty (30) day period when you will be available for mediation. ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ 7. Please provide the desired outcome of mediation 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. Date___________________________________________________________________ Name___________________________________________________________________ Company________________________________________________________________ Title___________________________________________________________________ Signature________________________________________________________________
[INFO BELOW THIS LINE FOR INTERNAL USE ONLY] Case No.:___________________________ Mediation Date:_______________________ |
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