Page 1 of 2 NOTE: If there is a contract that provides for mediation, please 037le 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 037le this form via email at case037ling@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 Person222s Name if an individual.) * Name of Party 2:(Company, Organization, or Person222s Name if an individual.) * Email Address: * Email Address: * Con037rm Email Address: * Con037rm Email Address: * Address: * Address: * City: * State: * Zip Code: * City: * State: * Zip Code: * Telephone: Fax: * Telephone: Fax: Representative Information (if applicable):Select 223YES224 if Self-Represented: Yes Name: Representative Information (if applicable):Select 223YES224 if Self-Represented: Yes Name: Name of Firm (if applicable): Name of Firm (if applicable): Email Address: Email Address: Con037rm Email Address: Con037rm Email Address: Address: Address: City: State: Zip Code: City: State: Zip Code: Telephone: Fax: Telephone: Fax: * Name of Person Filing this Submission: * Please indicate the category that best describes the nature of the dispute: Commercial Construction Employment Other (specify): * Does this matter involve more than two parties? Yes No(If 223Yes224, the AAA will contact you to obtain the additional party222s/parties222 information.) American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 * Requested Mediation Locale (city & state): * Have parties mutually agreed to a mediator? Yes No If 223Yes224 enter name of mediator: If the parties wish for AAA Mediation.org to directly select a mediator based on availability for your requested conference date, please initial here: * Summary of Dispute: 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 Speci037c Date(s) A $250 non-refundable deposit, which will be applied toward the cost of mediation, is required to initiate the AAA222s administration of the mediation and appointment of the mediator. For additional information, please view the AAA222s Administrative Fee Schedule. American LegalNet, Inc. www.FormsWorkFlow.com