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 Counsel Mediation Deadline Date: Urgent/Rush Copy of Mediation Order Attached No Mediation Order/Parties Agreed to Mediate OK to Unilaterally Set Time/Hours Needed : Hours Minutes AM PM AM/PM Other Payment: 50/50 Split Plaintiff 100% Defendant 100% Responsible for Notice: Plaintiff Defendant GMG Preferred Mediation Location: Attorney’s Office Inspired Mediation Office Plaintiff Defendant Pre-Suit or Circuit Court Case #: Judge: Judicial Circuit: Your Information:Plaintiff Attorney Defendant Attorney Pro se’ Attorney: Phone:Firm: FAX: Address: E-mail: City State / Province / Region ZIP / Postal Code Coordinator: Phone:Email: Opposing Counsel/Party Information: Plaintiff Attorney Defendant Attorney Pro se’ Attorney: Phone:Firm: FAX: E-mail: Address: Street Address City State / Province / Region ZIP / Postal Code Assistant: Δ