Maryland's On-Line Mediation Service
........................................mediation anytime, anyplace™......................................

 

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Mediation Submission Form

This form is designed to collect some basic information about you and to provide you with a mechanism for submitting your dispute for mediation.

Please provide the following contact information:

            Name 
           Title 
        Employer 
      Work Phone 
      Home Phone 
             FAX 
          E-mail 
             URL 

Please provide this additional information:

   Spouse's Name   
Your Date of birth 
             Sex Male Female

Have you ever been in a mediation ?

Yes No

Are you represented by counsel. ?

Yes No

Which browser are you using?


What will you be ready to begin mediation?

-- mm/dd/yy

Please describe your dispute and indicate the issues you want to mediate:


How much would you be willing to pay towards the cost of the mediator's fee? [There is no charge for mediation during this beta stage].


Enter a proposed password in the space provided below.[Combination of 8 characters or numbers].


What kind of computer do you have access to? What is the speed of your modem?



Copyright 1996, The Center for On-Line Mediation™, Inc.
Send comments on this web site to info@mediate-net.org
Last Revised on September 13, 1996

 

 

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