MEDIATION REQUEST

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.