AMERICORD, an affiliate of Burk & Landrum, P.A.,  and the undersigned parties, persons and entities, this _________ day of _______________, 200_, agree that: 

1.       The undersigned parties and their representatives seek to resolve through mediation a certain controversy identified as _____________v. ___________ and they have jointly retained AMERICORD to provide a neutral third party to facilitate their settlement  negotiations.

2.       The mediator will not act as advocate, representative, fiduciary or counsel for any party and will have no formal coercive authority to make any binding decisions or recommendations or to compel the making of any agreement or the granting of any concession.

3.       Participation in the mediation is voluntary; at any time, upon notice to the mediator, parties or their representatives may terminate their participation.

4.       The parties acknowledge that prior to the commencement of the mediation they were provided with a written statement of qualifications of the mediator assigned to the controversy, including a description of his or her educational background and relevant training and experience in mediation.

5.       The parties acknowledge their confidence in the impartiality of the mediator and AMERICORD and in the integrity of the mediation process, notwithstanding the fact that fees for mediation services may be paid by one party, and that the existence of such fee arrangement was fully disclosed prior to the commencement of mediation. The parties further agree to pay promptly upon receipt AMERICORD's invoice for fees and expenses (if any) in accordance with the firm’s standard fee schedule or other agreement regarding fees; counsel for the parties guarantee payment of such fees and expenses.

6.       The mediation constitutes settlement discussions under the applicable rules of evidence, and nothing said or disclosed during the mediation, nor any document produced in mediation, which is not otherwise discoverable, shall be admissible as evidence or usable for impeachment or other purposes in any judicial, arbitration or administrative proceedings. 

7.      No party or participant in the mediation process will call or subpoena the mediator to produce in any civil action, arbitration, or other legal or administrative proceedings of any kind whatsoever any notes or documents related to the mediation or to testify regarding any notes or documents or the mediator’s thoughts or impressions.  If so called or subpoenaed by anyone, the mediator will refuse to testify or to produce such notes or documents.  Should any party or other signatory to this Agreement or any other participant in the mediation process or any non-participating third party, entity or agency, attempt to compel such testimony or production, the parties or signatories to this Agreement, upon notice from AMERICORD, shall defend and indemnify at their joint and several expense, AMERICORD and the mediator against any liabilities, costs or expenses, including reasonable attorneys’ fees, which AMERICORD or the mediator may incur resisting such compulsion

Mediator:_________________________________________

Signatories:  SEE APPENDIX A