The undersigned parties are unable to resolve their differences through direct negotiations and are identified by name and, in addition, by the address and telephone number of themselves or their counsel (also named) as follows:

The nature of the dispute is as follows:

Please enter submitter's email address:
A copy of this form will be sent to this address, so please double check it for accuracy.

This dispute arises does not arise under a commercial contract. If it so arises, the commercial contract will be attached to this Submission agreement and the provision in dispute appears on page at paragraph ; the mediation clause appears on page at paragraph .

Other relevant documents will be will not be attached.

We have read the Mediation Rules of the Chicago International Dispute Resolution Association ("CIDRA"), with particular attention to the ground rules described in Article 20 of those Rules, and we voluntarily agree to submit our dispute to mediation administered by CIDRA under its Rules, as modified by agreement of the parties as follows:

We have agreed to use the services of the following mediator or mediators identified by name, address, and telephone number:

If we have listed no mediator, we request that a mediator co-mediators be appointed by CIDRA in accordance with Article(s) 7 or 8 of its rules. We agree that the appointed mediator(s) should have the following special qualifications:

We agree that the place of the mediation should be:

We agree that the language(s) of the mediation should be:

We agree that each party will have an individual present at the mediation who has full settlement authority to resolve the dispute.

We agree that all statements by the parties, the mediator, or CIDRA relating to the mediation process, and any documents created for or during these proceedings, are inadmissible and not discoverable for any purpose, including impeachment, in any pending or subsequent judicial, quasi-judicial, arbitration, or any other proceeding, absent consent of all parties. Neither the mediator nor anyone else associated with CIDRA will be subpoenaed to testify by any party for any reason. However, it is understood by the parties that evidence that is otherwise admissible or discoverable shall not be rendered inadmissible or non-discoverable as a result of its use in the mediation proceedings.

We agree to make deposits for the estimated fees and expenses and to pay any additional fees and expenses for which they are obligated in a timely manner as requested by CIDRA and in accordance with the provisions of Articles 25, 26, and 27 of the CIDRA Mediation Rules.

Submitting this form only notifies CIDRA of intent to proceed with mediation or arbitration. The following page will contain this information and will need to be signed by the submitting party(ies) and mailed to the Chicago International Dispute Resolution Association accompanied by the appropriate fee and copies of additional documentation. Please contact CIDRA directly if you have any questions.