REQUEST FORM

ANNEX A

Parties’ Request

Have all the parties agreed to mediate this matter?
Yes	No
Remarks:-

Filing Fee

Initiating Party - Contact Particulars

Salutation(if applicable)	:	Mr	Mrs	Ms	Others
Name	:
Address	:
Contact	:	Tel:		Fax:
Email Address	:

Contact Particulars (Legal Representatives / Experts)

Salutation(if applicable)	:	Mr	Mrs	Ms	Others
Name	:
Address	:
Contact	:	Tel:		Fax:
Email Address	:
Reference Number	:

Respondent Contact Particulars

Salutation(if applicable)	:	Mr	Mrs	Ms	Others
Name	:
Address	:
Contact	:	Tel:		Fax:
Email Address	:

Contact Particulars (Legal Representatives / Experts)

Salutation(if applicable)	:	Mr	Mrs	Ms	Others
Name	:
Address	:
Contact	:	Tel:		Fax:
Email Address	:
Reference Number	:

DETAILS OF THE DISPUTE

If court proceedings have started, please tick the applicable box:- Plaintiff Defendant Third Party
Quantum of claim	:	S$
Quantum of counterclaim	:	S$
Nature of Claim	:
Brief details of the dispute	:
Any Legal Suit	:
Details of Legal Suits & its Status	:

AVAILABLE DATES – FOR MEDIATION

[Please provide a few available dates]

MEDIATOR PREFERENCES

A.	Choice of Mediator (Please note that when parties choose their own mediator, the selected Mediator(s) is / are entitled to charge his / her commercial rates)
Name:
OR
B.	Parties wish for iiM to appoint appropriate Mediator(s):
	1. Mediator
	2. Mediators

Applicant’s Name
Signature
Date

• Please note that the non-refundable filing fee of $100.00 (GST, if applicable) per party will be payable within three (3) working days after iiM acknowledges the receipt of this request.

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