Complete Form THIS FORM IS FILLABLE The below information requested will assist us in expediting your information as quickly as possible Matter/Case Name:Your Firm File #:Case Type:(Preferred) Mediation Dates/Times:Mediation Already Scheduled with Opposing CounselMediation Deadline Date:Urgent/RushCopy of Mediation Order AttachedNo Mediation Order/Parties Agreed to MediateOK to Unilaterally Set Time/Hours Needed : Hours Minutes AM PM AM/PM OtherPayment: 50/50 SplitPlaintiff 100%Defendant 100%Responsible for Notice: PlaintiffDefendantGMGPreferred Mediation Location: Attorney’s OfficeInspired Mediation OfficePlaintiffDefendantPre-Suit orCircuit CourtCase #:Judge:Judicial Circuit:Your Information:Plaintiff AttorneyDefendant AttorneyPro se’Attorney:Phone:Firm:FAX:Address:E-mail: City State / Province / Region ZIP / Postal Code Coordinator:Phone:Email: Opposing Counsel/Party Information: Plaintiff AttorneyDefendant AttorneyPro se’Attorney:Phone:Firm:FAX:E-mail: Address: Street Address City State / Province / Region ZIP / Postal Code Assistant: Δ
