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First Name: (Required) Last Name: (R) Phone:   Email: (R) Business Name (if applicable):

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First Name: Last Name: Phone:   Email: Business Name (if applicable):   Are there other parties involved in this dispute? If so, list email addresses of other parties (one per line):

Please fill out these dispute details:

Nature of the dispute: Adoption Americans w/Disabilities Act Art Business Civil (general) Commercial Community Construction Contracts Criminal Cross Cultural Divorce (all issues) Divorce (parenting) Education EEOC Employment Engineering Environmental Family (other) Franchise General Insurance International Labor Management Land Use Landlord - Tenant Legal Malpractice Lesbian, Gay, Bi & Trans Issues Medical Native American Indian Disputes Online Mediation and Facilitation Organizational Partnership Dissolutions Police Postal Service Probate Professional Fee Disputes Public Policy Real Estate Religious / Church Securities Social Security Special Education Tax Technology Torts Victim Offender Mediation Work Place Worker's Comp What date did this dispute begin? January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1996 1997 1998 1999 2000 2001 2002 What is the approximate monetary value of the items under dispute? Less than $500 $500-$2,000 $2,000-$10,000 $10,000-$50,000 Greater than $50,000 This dispute is regarding... (R) What do you and the other party disagree about? (R) Are there any things you and the other party might agree upon? What has happened so far in this dispute? (phone calls, emails, etc.) What do you want to get from this mediation? (R) Please add anything else you think it would be helpful for a mediator to know:

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