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Request For Use Of A Private Mediator Form. This is a Official Federal Forms form and can be use in 11th Circuit Court Of Appeals Circuit Court Of Appeals.
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COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
:
:
Plaintiff(s)
-against-
Calendar No.
JUDICIAL SUBPOENA
:
Request for Use of a Private :
Mediator
:
Appeal Caption
_____________________________________________________________________
Defendant(s)
:
......................................................
Appeal Number(s)
_____________________________________________________________________
The undersigned parties in the above-captioned appeal(s) agree to employ the services of the private mediator
THE PEOPLE OF THE STATE OF NEW YORK
identified below for the purpose of conducting a mediation. The parties are aware of the requirements for use of a
private mediator as set forth in Eleventh Circuit Rule 33-1.
TO
___________________________________________
(Signature of Counsel for Appellant)
___________________________________________
(Signature of Counsel for Appellee)
GREETINGS:
Acceptance by Private Mediator:
____________________________________________________ accepts the
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
employment by
,
the Honorable the parties to conduct a mediation in the above-captioned appeal(s). Further, the mediator
at the
Court
located at
County of
represents to the court that he or she:
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
Has been certified or registered as a mediator by either the State of Alabama, Florida, or
or(1)
adjourned date, to testify and give evidence as a witness in this action on the part of the Georgia for the
preceding five years. State of certification and certification date: _________________________________.
(2)
Has been admitted to practice law in either the state of Alabama, Florida, or Georgia for the preceding
(3)
Is currently admitted to the bar of this court.
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf this subpoena was issued Stateaand date of admission: ________________________.
fifteen years and is currently in good standing. for maximum penalty of $50 and all damages sustained as a
result of your failure to comply.
Further, the undersigned mediator represents that he or she has read the “Private Mediator Procedures for Mediation
Witness, Honorable
, one of the Justices of the
Court in
County,
day of
, 20
of Appeals” and agrees to follow the procedures set forth therein.
___________________________________________
(Signature of Mediator)
___________________________________________
(Print Name)
___________________________________________
(Address)
___________________________________________
________________________________________
(Telephone)
(Attorney must sign above and type name below)
________________________________________
(Fax)
________________________________________
(Email)
Attorney(s) for
____________________________________________________
Please fax this completed form to the Kinnard Mediation Center 404-335-6270,
within ten days of the date of the court’s notice of mediation.
Office and P.O. Address
October 2004
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
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