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Request for Mediation
Request for Mediation
In the Matter of the Dispute Between the Following Parties:
___________________________ CLAIMANT
VS.
___________________________ RESPONDENT
TO:
.
Pursuant to the mediation clause (provision) of the written agreement (contract) dated ___________, 19 __, initiated between and , attached hereto and incorporated by reference, the undersigned claimant hereby demands mediation under the administration of ___________________________________.
Nature of Dispute and/or Injuries Alleged:
Relief Sought:
Requested Location for Mediation:
You are hereby notified that copies of this demand and our prior agreement to mediate are being submitted to ____________________________________ At its offices located at , with the request for initiate mediation pursuant to .
Signed this ____ day of ________________, 19 ___.
BY:________________________
cc: Agency to Administer the Mediation
© 1996 The Mediation Center Inc.
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