Mediation Initiation Form for Professional Licensure Cases

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This form is for the initiation of mediation on a professional licensure issue.

This form is not for initiating an IDEA mediation request.

Board

License #

Issue 1:

Issue 2:

Issue 3:

Duration

Half Day

Full Day

Agreed Upon or Proposed Dates and Times

First Date	First Hour Time	First Minute Time	First AM/PM Time
Second Date	Second Hour Time	Second Minute Time	Second AM/PM Time
Third Date	Third Hour Time	Third Minute Time	Third AM/PM Time
Fourth Date	Fourth Hour Time	Fourth Minute Time	Fourth AM/PM Time

Signature

Please type your name in the box below. By typing your name, you certify this information is accurate and certify that this will act as your binding electronic signature.

First Name

Middle Initial

Last Name

Suffix

Attorney Registration No.

Company

Address

City

State

ZIP

#####

Phone Number

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

Email Address

Contact Preference

You have selected traditional mail as your preferred contact method. This may result in delay in receipt of any procedural or final order. If you accept these terms, please check below. If you do not, please select "Email."

I accept

Licensee/Applicant Contact Information

First Name

Middle Initial

Last Name

Suffix

Company

Address

City

State

ZIP

#####

Phone Number

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

Email Address

Contact Preference

I accept

Does Licensee/Applicant have representation?

Yes

Licensee/Applicant Representative

Is the representative a licensed attorney?

YesNo

Attorney Reg #:

First Name

Middle Initial

Last Name

Suffix

Company

Address

City

State

ZIP

#####

Phone Number

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

Email Address

Agency/Board Contact Information

First Name

Middle Initial

Last Name

Suffix

Company

Address

City

State

ZIP

#####

Phone Number

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

Email Address

Does the Agency/Board have representation?

Yes

Agency/Board Representative

Is the representative a licensed attorney?

YesNo

Attorney Reg #:

First Name

Middle Initial

Last Name

Suffix

Company

Address

City

State

ZIP

#####

Phone Number

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

Email Address

By checking this box, you attest that you have conferred with all parties to this matter and that all parties agree to engage in mediation.

Name of Filer

Date

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