SUBMISSION TO MEDIATION * Required items are indicated with an asterisk (*) NOTE: If there is a contract that provides for mediation, please file using the Request for Mediation form. 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 Party 1: (Company, Organization, or Person's Name if an individual.) * Name of Party 2: (Company, Organization, or Person's Name if an individual.) * Email Address: * Confirm Email Address: * Address: * Email Address: * Confirm Email Address: * Address: * City: * Telephone: * State: Fax: * Zip Code: * City: * Telephone: * State: Fax: * Zip Code: Representative Information (if applicable): Select "YES" if Self-Represented: Yes Name: Name of Firm (if applicable): Email Address: Confirm Email Address: Address: Representative Information (if applicable): Select "YES" if Self-Represented: Yes Name: 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 Filing this Submission: * Please indicate the category that best describes the nature of the dispute: Other (specify): * Does this matter involve more than two parties? Yes No (If "Yes", the AAA will contact you to obtain the additional party's/parties' information.) Commercial Construction Employment Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com SUBMISSION TO MEDIATION * Required items are indicated with an asterisk (*) * Requested Mediation Locale (city & state): * Have parties mutually agreed to a mediator? * Summary of Dispute: Yes No If "Yes" enter name of mediator: Claim or Relief Sought: (amount, if any) * Allocation of Costs: % Party 1 % Party 2 * 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) 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