APPLICATION TO
APPOINT A MEDIATOR

The Applicant hereby requests the New Zealand Dispute Resolution Centre (NZDRC) to appoint a Mediator and to manage and administer the procedures in relation to that Mediation.

***Please ensure that you complete this application carefully and that all details provided are correct***

1. First Party’s Details
2. Second Party’s Details
Add another Party
2a. Third Party’s Details
Add another Party
2b. Fourth Party’s Details
3. Applicant’s Details (Please complete only if different from First Party’s details)
4. Brief Description of the Nature of the Dispute
5. The Relief, Remedy, or Outcome that is sought
6. Agreement to Mediate
Yes No
7. Special Requests/Requirements of Mediator
Yes No
8. Panel of Mediators
Yes No
9. Security Amount

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