Request for Mediation Form

Full name (EHO):

Council name:

I refer for mediation the matter outlined below.

The parties have agreed that they are willing to participate in the mediation and have been provided with the mediation information brochure. All criteria for the Environmental Dispute Mediation assessment process have been met.

Request Date:

Phone contact:

Email address:

If mediation involves more than 3 parties please advice why you consider this matter is suitable for mediation as part of the Environmental Dispute Mediation Trial.

FIRST PARTY DETAILS

TITLE: Mr Mrs Ms Other

Family name:

Given name:

Residential address:

Postal address:

Phone/Home:

Phone/Mobile:

Fax:

Email:

SECOND PARTY DETAILS

TITLE: Mr Mrs Ms Other

Family name:

Given name:

Residential address:

Postal address:

Phone/Home:

Phone/Mobile:

Fax:

Email:

THE DISPUTE

DETAILS OF THE DISPUTE:

Under what provision of EMPCA has the dispute occurred?:

What regulatory options been explored?:

ANY OTHER COMMENTS OR RELEVANT INFORMATION:

If known has there been any police involvement? Provide an outline where known.: