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Request for Mediation

Before submitting this request for mediation, be sure you:

1. Have made a good-faith effort to settle with the other party. Approximate Dates:

2. Attach a copy of any contracts and other documents important to this matter.

3. Read our online brochure "Mediation: Assistance in Negotiating Disputes," understand the mediation process, and agree to the rules that apply to mediation.

Petitioner

Name:
Affiliation:
BYU ID #:
Current Mailing Address:
City:
State:
Zip:
Permanent Home Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Cell Phone:
Email:
Where can you be reached Mon. - Fri.:
When are you available for mediation Mon. - Fri.:

Other Party

Name:
Affiliation:
BYU ID #:
Current Mailing Address:
City:
State:
Zip:
Permanent Home Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Cell Phone:
Email:

Issues to be Discussed:


Suggested Recommendation for Resolution of Problem: (Please limit your response to 200 words.)


How did you become aware of the BYU CCR mediation services:


Submitted By (by entering your name here, you are adding your digital signature.):

By submitting this application, I am confirming that the information provided is true and correct.