FE DE RAL MEDI A TION PR OG RAM EA STERN DISTRICT OF TENNESSEE ___________________________________________________ v. __________________________________________ _________ Docket No. _________________________________________ Type of Case _______________________________________ (Indicate number from Item V "Natu re of Suit" from the Civil Cover Sheet Form JS 44 ). APPLICATION FOR MEDIATION INFORMATI ON ABOUT 1ST PARTY : Name: __________________________________________ ___________________________ First Middle LastStreet Address: ____________________________________ ____________________ City, state, zip code: ______________________________ ______________________ Age: ______________________ _____________ Home phone: ____________________________ Work phone: ____________________________ Attorneys name: _________________________ Work phone: ____________________________ Please identif y the principals for any closely held corporation, identi fy all partners of a generalpartnership, identi fy the general partner of any limited partnershi p and all principals of any limitedliability company involved in the medi ati on. __________________________________________ ___________________________ __________________________________________ ___________________________ INFORMATI ON ABOUT 2ND PARTY : >>>> 2Name: __________________________________________ ___________________________ First Middle LastStreet Address: ____________________________________ ____________________ City, state, zip code: ______________________________ ______________________ Age: ______________________ _____________ Home phone: ____________________________ Work phone: ____________________________ Attorneys name: _________________________ Work phone: ____________________________ Please identif y the principals for any closely held corporation, identi fy all partners of a generalpartnership, identi fy the general partner of any limited partnershi p and all principals of any limitedliability company involved in the medi ati on. __________________________________________ ___________________________ __________________________________________ ___________________________ PLE ASE PROV IDE INFOR MAT ION ON A NY OT HER PAR TIES INVOL VED IN ME DIATION : (Use back side of form if more room is needed). Name: __________________________________________ ___________________________ First Middle LastStreet Address: ____________________________________ ____________________ City, state, zip code: ______________________________ ______________________ Age: ______________________ _____________ Home phone: ____________________________ Work phone: ____________________________ Attorneys name: _________________________ Work phone: ____________________________ Please identif y the principals for any closely held corporation, identi fy all partners of a generalpartnership, identi fy the general partner of any limited partnershi p and all principals of any limitedliability company involved in the medi ati on. >>>> 3__________________________________________________________________________________________________________________________________________________________________________________________________________________WE HA VE SEL ECT ED T HE F OLLO WING M EDIATOR : __________________ ___________________The m ediator listed above has bee n select ed from the list of qualified mediators provided by the FederalCo urt. All mediation services will be provided on a contrac t basis for a specified rate, to be arra nge d withand paid directly to the mediator. The Fede ral Court does not endorse particular me diators. Mediatorsare independent contrac tors. The med iator will contact you prom ptly. No filing fee for this application isrequired. WE WERE REFE RRED TO THE FEDERAL MEDIATION PROGRAM BY : __________ At torney Recomm ended __________ Judge Recomm ended ______ ____ OTHER (please explain) _____________________ ________________ _____________________ _________________ Signature and Printed Name of Attorney Date for One of the Part ies MAIL /DELI VER THI S APPLI CATION TO : Knoxville/W inchest er Cases Greenevi lle Cases Chattano oga Casesc/o U.S. District Court Clerk c/o U.S. District Court Clerk c/o U.S. District Court ClerkATTN : Mediation Coordinator ATTN : Mediation Coordinator ATTN : Mediation Coordinator800 Market St reet, Suite 130 220 W . Depot Street , Sui te 200 900 Georgia Ave., Rm . 309Knoxville, TN 37902 Greenevi lle, TN 37743 Chattano oga, TN 37401