APPENDIX 1

Request for Mediation

(where there is no agreement to refer a dispute
to the Office of the Judiciary Out-of-Court Mediation Rules)

The Request for Mediation shall include:

• the names, addresses, telephone and facsimile numbers, and e-mail addresses of the parties to the dispute, and of their authorized representatives or attorneys, if any;
• a description of the dispute including, if possible, the amount or value that is in dispute; and
• [the registration fee for the Mediation process, as set out in Appendix 5.] Optional: see preface to Article 11.

Any proposal regarding the qualifications of a Mediator: ____________________________

________________________________________________________________________

Name of the proposed Mediator: __________________________________

List of Mediators that would be qualified to serve in the Mediation of the dispute if the other party or parties also so designated:

_____________________________

_____________________________

The Request must be sent to:

Address:

Fax:

E-mail:

[The accompanying registration fee is payable:

-     by cheque to the order of the _______________________

Requestors:

_____________________________

_____________________________