Request Mediation

Submit a Request for Mediation with an AAA Office

Required items are indicated with an asterisk(*).

Please complete the Request for Mediation form below. The information you provide is solely for the purpose of managing your mediation. Thank you for choosing the mediation services of the American Arbitration Association. (If you have questions please email mediationservices@adr.org.)

REQUEST FOR MEDIATION

Is there a contract between the parties that contains an agreement to mediate by the AAA?

Yes

Upload a copy of the contract clause calling for AAA mediation.

File:

If you do not have a way of uploading a copy of the contract clause, you may fax the page(s) to 877-304-8457. Please include the names of the parties to the contract on the fax cover transmittal page.

If there is NO contract calling for mediation or if the mediation clause does not specify the AAA, have the parties agreed to

mediation by the AAA?

Yes

Not Applicable

If No, the AAA will contact the opposing party to seek their agreement to mediate.

Indicate the category that best describes the nature of your dispute.

Commercial

Construction

Employment

Other(specify)

Requested Mediation Locale (city & state)

Is there a particular mediator you want to request?

Yes

If Yes, enter name here:

Has the requested mediator been mutually selected by the parties.

Yes

Not Applicable

Does this matter involve more than two parties.

Yes

(If "Yes", the AAA will contact the filing party's representative to obtain the additional party's/parties' information.)

Name of Person Submitting this Request:

Party 1 Information (Filing Party)

* Name of Party 1:

(Company/Organization. Enter a person's name only if the party is an individual.)

	Email Address:
	Confirm Email Address:
	* Address Line 1:
	Address Line 2:
	Address Line 3:
	* City:
	* State:
	* Zip Code:
	* Telephone:
	Fax:

Party 1 Representative Information

(If self-represented click

to copy the above information to the representative.)

	* First Name:
	* Last_Name:
	Firm/Business Name
	* Email Address:
	* Confirm Email Address:
	* Address Line 1:
	Address Line 2:
	Address Line 3:
	* City:
	* State:
	* Zip Code:
	* Telephone:
	Fax:

* Summary of Dispute:

Claim or Relief Sought: (amount, if any)

Party 2 Information (Responding Party)

* Name of Party 2:

(Company/Organization. Enter a person's name only if the party is an individual.)

	Email Address:
	Confirm Email Address:
	* Address Line 1:
	Address Line 2:
	Address Line 3:
	* City:
	* State:
	* Zip Code:
	* Telephone:
	Fax:

Party 2 Representative Information

(If self-represented click

to copy the above information to the representative.)

	* First Name:
	* Last_Name:
	Firm/Business Name
	* Email Address:
	* Confirm Email Address:
	* Address Line 1:
	Address Line 2:
	Address Line 3:
	* City:
	* State:
	* Zip Code:
	* Telephone:
	Fax: