EmailMe Form - NTM Mediator Appointment Request Form

Name of Requesting Party *

Requesting Party's Email Address *

Telephone for Requesting Party *

### - ### - ####

Address of Requesting Party

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Please confirm that the parties have been unable to select a mediator within the time required by the governing Regulation *

I Confirm

Please clearly identify the section of the Regulation under which the request is being made (ie: Section 7 of the Notice to Mediate (General) Regulation, Section 7 of the Insurance (Motor Vehicle) Act Notice to Mediate Regulation, Section 7 of the Law & Equity Act Notice to Mediate Regulation, or the Section 4 of the School Act Notice to Mediate Regulation. *

Please list the names and contact information (including an address, phone number, fax number and email address) of counsel involved in the Action, as well as the names of the parties which they represent. The submission should also indicate contact information for any unrepresented parties. Note: If the submission is made under the Notice to Mediate (General) Regulation, it should state the nature of the Action (e.g., wrongful dismissal, personal injury). *

Please indicate either the date of the Trial or indicate that a Trial date has not been scheduled. *

Note: if the request is made under the Notice to Mediate (General) Regulation, it should indicate the date of the filing of the first response. If the request is made under the Notice to Mediate Regulation [Insurance (Motor Vehicle) Act], it should indicate the date that Pleadings were closed.

Please provide a complete copy of the Notice to Mediate corresponding to this request, and confirm the dates on which the Notice to Mediate was delivered to each of the participants involved in this dispute.