Forms > Requests for Mediation > Request II
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 in resolution of the dispute specified below.
Nature of Dispute and/or Injuries Alleged:
Relief Sought:
Requested Location for Mediation:
You are hereby requested to contact claimant (or claimant’s representative) to discuss the necessary details to arrange for commencement of mediation.
SIGNED this ____ day of ________________, 19 ___.
BY: ___________________________ Attorney for Claimant
© 1996 The Mediation Center, Inc.
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