REQUEST FOR MEDIATION * Required items are indicated with an asterisk (*) NOTE: Only use this form to file a mediation if there is a contract that provides for mediation by the AAA. If there is no contract providing for mediation or if the mediation clause does not specify the AAA, please file using the Submission to Mediation form. Please send a copy of the contract's mediation clause along with this form at the time of filing. The information you provide is solely for the purpose of managing your mediation. If you are using Acrobat Reader 8.0 or higher, you should be able to save the form once completed. After completing the form please save it to the hard drive on your computer before navigating away from the form. If you navigate away from the form before saving it your data will be lost. Once you have completed and saved the form, send it simultaneously to us and the opposing party/parties. You may file this form via email at casefiling@adr.org, via fax at 1-877-304-8457, or via U.S. mail at American Arbitration Association, Case Filing Services, 1101 Laurel Oak Road, Suite 100, Voorhees, NJ 08043. If you have any questions please email us at mediationservices@adr.org. * Name of Requesting Party: (Company, Organization, or Person's Name if an individual.) Name of Representative (if applicable): Select "YES" if Self-Represented: Yes * Email Address: * Confirm Email Address: * Address: Name of Firm (if applicable): Email Address: Confirm Email Address: Address: * City: * Telephone: * State: Fax: * Zip Code: City: Telephone: State: Fax: Zip Code: * Name of Person Submitting this Request: * Please indicate the category that best describes the nature of your dispute: Other (specify): * Does this matter involve more than two parties? Yes No (If "Yes", please attach an additional page listing the names and contact information of any parties beyond two.) * Requested Mediation Locale (city & state): * Have parties mutually agreed to a mediator? * Summary of Dispute: Yes No If "Yes" enter name of mediator: Commercial Construction Employment Claim or Relief Sought: (amount, if any) * Please indicate your preference for when you would like the actual mediation conference to be conducted: Within 7 business days Within two weeks Within 30 days Later than 30 days Specific Date(s) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com REQUEST FOR MEDIATION * Required items are indicated with an asterisk (*) * Name of Responding Party: (Company, Organization, or Person's Name if an individual.) Name of Representative (if known): * Email Address: * Confirm Email Address: * Address: Name of Firm (if applicable): Email Address: Confirm Email Address: Address: * City: * Telephone: * State: Fax: * Zip Code: City: Telephone: State: Fax: Zip Code: A $250 non-refundable deposit, which will be applied toward the cost of mediation, is required to initiate the AAA's administration of the mediation and appointment of the mediator. For additional information, please view the AAA's Administrative Fee Schedule. Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com