Mediation Request Form (to be completed by referring party)

send via intercampus mail to Angelica Antunez, Centennial Hall 438 

Name of referring party:__________________________________           Date:_____________

Name of disputant(s) (include yourself if you are a disputing party):

1.  _____________________________________________

2.  _____________________________________________

3.  _____________________________________________

4.  _____________________________________________

Complete the rest of this form only if you are not completing a Disputant Information Form also.

Description of conflict: 

______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________

Your relationship to the conflict and disputants: 

______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________

Other pertinent information: 

______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________