Request for Mediation Form

In the matter of Claimant: ______________________________________________ vs.

Respondent: ________________________________________________________

I am requesting mediation with the above-named disputant prior to a hearing of this dispute by the Professional Standards Committee of the Association. There is due, unpaid, and owing to me (or I retain) from the above-named person the sum of $___________________. My claim is predicated upon the statement attached, marked Exhibit One and incorporated by reference into this application.

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Signature of REALTOR® Principal/Authorized Designee

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Type or Print Name

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Date

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Firm Name

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Address: (City State Zip)

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Phone