Civil Mediation Intake Form - Commercial/Business Disputes

This form is for disputes involving commercial or business matters. While one party of the dispute may be an individual, the dispute itself is of a business matter and at least one of the parties should be a business or corporation. Please complete this form as thoroughly as possible. Use "N/A" if something is not applicable. Use "Don't Know" if you are unsure of the answer.

Preferred Date to Mediate:

1st Alternate Date:

2nd Alternate Date:

Preferred Session

If half-day requested, is there a preferred start time?

Have selected dates been confirmed by all the parties?

Yes
No
Don't Know

Please select the type of dispute:

Please provide a brief description of your dispute here:

Contested Amount:

Contested Amount: :: How much money is at stake in the dispute? Must be entered in $00.00 format.

Case Name or Style No.:

Cause No. (if any):

Court (if any):

YOUR PERSONAL INFORMATION

What is your position in this dispute?

First Name

Last Name:

Company Name

Company Name :: Type N/A if you are an individual or sole proprietor without a company name.

Mailing Address:

Primary Telephone #:

Secondary Telephone #:

Email Address:

Attorney's Name (if any):

Law Firm (if any):

Attorney/Law Firm Telephone #:

Attorney/Law Firm Fax #:

Attorney's Email Address:

ADDITIONAL PARTIES & REPRESENTATIVES

Party 2

2nd Party's position in this dispute:

2nd Party's Full Name:

2nd Party's Full Name: :: Type the name of the person with whom you have been in contact with.

Company Name

Company Name :: Type N/A if party is an individual or sole proprietor without a company name.

2nd Party's Mailing Address:

2nd Party's Telephone Number:

2nd Party's Email Address:

Attorney's Name (if any):

Law Firm (if any):

Attorney/Law Firm Telephone #:

Attorney/Law Firm Fax #:

Attorney's Email Address:

Other Parties Involved

Please list any additional parties, along with their contact information and how they are involved in the dispute. If there are not other parties involved, please type "N/A" in this field.

Please list any additional parties, along with their contact information and how they are involved in the dispute. If there are not other parties involved, please type "N/A" in this field. :: If there are just two parties, please type N/A here.

Resources

Resources for Court Officials

For more information about conflict management or to schedule a mediation, please give us a call at:

(469) 293-4237

We are available 24 hours a day to assist you with your dispute resolution needs!