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Commercial and Workplace Mediation
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Commercial & Workplace Mediation Inquiry Form
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Client Information
Date
(required)
Your First Name
(required)
Your Last Name
(required)
Job Title
Company Name
Mailing Address
(required)
Email Address
(valid email required)
Cell Phone Number
Work Phone Number
Are you directly involved in the dispute/conflict situation?
Yes
No
Case Information
Please explain briefly what issue(s) you would like to discuss during mediation
(required)
Do you have any apprehension regarding emotional and/or physical intimidation from the other party(s) ?
If so, please explain:
Other party(s) names(s) and daytime contact information:
First Name: Last Name: Phone Number: E-mail Address:
What is your relationship to the other party(s)?
Is mediation required by a contract related to this case?
Are the issues to be addressed in mediation part of a current court case?
Yes
No
If yes, please provide the following:
Court
Type of hearing
Hearing date (mm/dd/yyyy)
Case number
Additional Comments/Questions
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