APPLICATION FOR MEDIATION PROGRAM
Name and contact details of person completing form:
Title
*
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Mx.
First Name
*
Last Name
*
Email Address
*
Contact Number
Details of your solicitor (if you are legally represented):
Title
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Mx.
Full Name
Firm
Address
Contact Number
Email
I confirm that all parties to the dispute agree to this application for mediation:
Yes
No - please contact us on (02) 9926 0396 or email a2j@lawsociety.com.au
Name of Party 1
Name of Party 2
Are there any other parties to the dispute
Yes
No
Please provide the name of any other parties to the dispute:
Name of Party 3
Name of Party 4
Description of the dispute:
*
Court Details (if applicable):
Court
Next Court Date
Reason for Listing
Details of solicitor for Party 2: (if applicable)
Details of solicitor for Party 3: (if applicable)
Title
*
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Title
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Mx.
Full Name
*
Full Name
Firm
Firm
Address
Address
Contact Number
Contact Number
Email
Email
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