SUPREME COURT OF THE STATE OF NEW YORK COMMERCIAL DIVISION- COUNTY OF NASSAU -------------------------------------------------------X Part ___ Plaintiff, Index No. ______ - against MEDIATION INITIATION FORM Defendant, ------------------------------------------------------X (1) This case was referred to mediation through the Nassau County Commercial Division’s ADR Program (order of Justice _____________ dated ___________). (2) Pursuant to Rule 3 of the Nassau County Commercial Division ADR Program’s Rules, located at http://www.nycourts.gov/courts/comdiv/nassau.shtml , the parties have conferred and (CHECK APPROPRIATE BOX BELOW): a. 9 Selected the following to serve as mediator. ______________ Name b. 9 _______________ Address _______________ Phone ____________ Email Are unable to agree on a mediator and submit the following 4 (four) names from which the Court may assign a mediator. ______________ Name _______________ Name _______________ Name ___________ Name ______________ Address _______________ Address _____________ Address ______________ Address ______________ Phone ________________ Phone ______________ Phone _______________ Phone ______________ Email ________________ Email ______________ Email _______________ Email American LegalNet, Inc. www.FormsWorkFlow.com (3) For the mediator to run the required conflicts check, counsel for any corporate party must list here or on an attached sheet the names of all corporate parents, subsidiaries or affiliates: --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------(4) Please indicate whether there are in this case: Motions sub judice: Yes __ No__ Appeals: Yes __ No __ If you indicated yes to either of the foregoing, please contact the Court immediately. (5) The attorneys for the parties herein are as follows: For Plaintiff: For Defendant: Phone: ________________________ E-Mail: ________________________ Phone: ______________________ E-Mail: _____________________ (6) This form shall be completed and returned to the Court and the selected mediator within 5 business days from receipt of the Order of Reference. This deadline will not be extended. The initial mediation session must be conducted within 45 days from the date of the Order of Reference (see Rule 3 (e)). At least one week before the initial session, each party shall deliver to the mediator a memorandum of not more than three pages (see Rule 3(f)). (7) By signing below, the parties and their Counsel, certify that they have read and will comply with the ADR Rules of the Nassau County Commercial Division. The parties and their Counsel further understand and agree that the mediation process is confidential and that the mediator shall be immune from suit by any of the parties or other participants in this case because of or based upon the mediator’s activities as such in this matter to the extent permitted by law. Parties agree that no attorney-client relationship exists between the mediator and the parties, and the mediator shall not provide legal services to the parties during the process. _____________________ Counsel for Plaintiff _____________________ Counsel for Defendant Date:_________________ American LegalNet, Inc. www.FormsWorkFlow.com