NKU Alternative Dispute Resolution Center

Request for Mediation

Your Name required	Name of Other Party:
Address: required	Other Party's Address:
City/State/Zip: required	Other Party's City/State/Zip:
Phone where you can be reached: required Alternate Phone:	Other Party's Phone:
Email: (If you provide an email address here, you will receive an email with the contents of this form)
Brief description of dispute:

Attorney consulted? Yes No	Retained? Yes No
When you submit this form, you can expect someone from the Alternative Dispute Resolution Center to contact you shortly.

Request for Mediation