Application to Appoint a Mediator

1. First Party’s Details

Name:
Contact Person/Representative:
Address for Service of Notices and documents in relation to Mediation:

Post Code:		Phone:
Fax:		Mobile:
Email:

2. Second Party’s Details

Name:
Contact Person/Representative:
Address for Service of Notices and documents in relation to Mediation:

Post Code:		Phone:
Fax:		Mobile:
Email:

Add another Party

2a. Third Party’s Details

Name:
Contact Person/Representative:
Address for Service of Notices and documents in relation to Mediation:

Post Code:		Phone:
Fax:		Mobile:
Email:

Add another Party

2b. Fourth Party’s Details

Name:
Contact Person/Representative:
Address for Service of Notices and documents in relation to Mediation:

Post Code:		Phone:
Fax:		Mobile:
Email:

3. Applicant’s Details (Please complete only if different from First Party’s details)

Name:
Position/Role of Applicant:
Address for Service of Notices and documents in relation to Mediation:

Post Code:		Phone:
Fax:		Mobile:
Email:

4. Brief Description of the Nature of the Dispute

5. The Relief, Remedy, or Outcome that is sought

6. Agreement to Mediate

A copy of the parties’ agreement to refer the dispute to Mediation by Mediator appointed by NZDRC is attached?

Yes No

7. Special Requests/Requirements of Mediator

7.1 Please state any preferred expertise / knowledge / professional background (if any) of the person to be appointed as Mediator:

7.2 Are the parties in agreement as to the preferred expertise?

Yes No

7.3 A copy of the document recording the parties’ agreement as to the Mediator’s expertise is attached:

8. Panel of Mediators

*Please advise whether the parties have reached agreement as to any person (or persons) on our Panel of Mediators whom they wish to request NZDRC to appoint as Mediator in this matter (please note that NZDRC will have regard to any such agreement but will not be bound by it, and any appointment will be at the sole discretion of the Registrar)

8.1 Are the parties in agreement as to whom they wish to act as Mediator in this matter?

Yes No

8.2 Please name the person (or persons):

8.3 A copy of the document recording the parties’ agreement as to the Mediator is attached:

9. Security Amount

Payment may be made by direct credit, cheque or credit card on the next page.

9.1 Please select Mediation Code: (See Schedule B to the Agreement to Mediate)

Please note: If your Code is MM1 or MFR we will contact you to finalise the amount to be paid and arrange for payment

9.2 Please enter the amount in Dispute (inclusive of GST) (ie. Enter 98643.00 if the amount of your claim is $98,643.00)

Please note: If your Code is MFR please enter 0 as the amount in dispute below

Amount in Dispute: NZ$

Security Amount: NZ$

Calculate Security Amount

10. Agreement

I confirm that the information I have supplied is true and correct to the best of my knowledge and that I have read and accepted the terms and conditions of the New Zealand Dispute Resolution Centre Ltd

Please print a copy of your application for your records

APPLICATION TO APPOINT A MEDIATOR

APPLICATION TO
APPOINT A MEDIATOR