REQUEST FORM
ANNEX A
Parties’ Request |
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Have all the parties agreed to mediate this matter? | |
Yes | No |
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Remarks:- |
Filing Fee |
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Initiating Party - Contact Particulars |
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Salutation(if applicable) | : | Mr | Mrs | Ms | Others |
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Name | : | ||||
Address | : | ||||
Contact | : | Tel: | Fax: | ||
Email Address | : |
Contact Particulars (Legal Representatives / Experts) |
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Salutation(if applicable) | : | Mr | Mrs | Ms | Others |
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Name | : | ||||
Address | : | ||||
Contact | : | Tel: | Fax: | ||
Email Address | : | ||||
Reference Number | : |
Respondent Contact Particulars |
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Salutation(if applicable) | : | Mr | Mrs | Ms | Others |
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Name | : | ||||
Address | : | ||||
Contact | : | Tel: | Fax: | ||
Email Address | : |
Contact Particulars (Legal Representatives / Experts) |
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Salutation(if applicable) | : | Mr | Mrs | Ms | Others |
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Name | : | ||||
Address | : | ||||
Contact | : | Tel: | Fax: | ||
Email Address | : | ||||
Reference Number | : |
DETAILS OF THE DISPUTE |
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If court proceedings have started, please tick the applicable box:-
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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 |
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[Please provide a few available dates] |
MEDIATOR PREFERENCES |
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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) |
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Name: | |
OR | |
B. | Parties wish for iiM to appoint appropriate Mediator(s): |
1. Mediator | |
2. Mediators |
Applicant’s Name | |
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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.