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Transmittal Form
Case Name:
Date Submitted:
Submitted By:
Is this case in suit?
Trial Date:
Discovery Date:
Mediation Date:
Brief Description of Claim:

Are all Parties in Agreement to Mediate?

Party 1

Client's Full Name:
Attorney's Name:
Address:
City:
State:
Zip:
Phone:
Fax:

Party 2

Client's Full Name:
Attorney's Name:
Address:
City:
State:
Zip:
Phone:
Fax:

Party 3

Client's Full Name:
Attorney's Name:
Address:
City:
State:
Zip:
Phone:
Fax:

Party 4

Client's Full Name:
Attorney's Name:
Address:
City:
State:
Zip:
Phone:
Fax:

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