Administered Mediation Request Form

Request for Administered Mediation

REQUEST FOR MEDIATION

The Referring Party is required to complete the form below insofar as the information required is available to it.

The Referring Party is required to submit this form to the AFSA Secretariat by email at mediation@arbitration.co.za.

The AFSA Secretariat can be contacted by telephone to ensure the application form has been received – telephone number. 011 320 0500.

A1. DETAILS OF REFERRING PARTY

Name(Required)

Registration No (if a Juristic person):

VAT Number (if applicable):

Physical Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Postal Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Telephone No:(Required)

Email address:(Required)

Finance Email address:(Required)

Party representative (if any):

Telephone No:(Required)

Email Address:(Required)

A2. DETAILS OF RESPONDENT / OTHER PARTY

Name:(Required)

Registration No (if a Juristic person):

VAT Number (if applicable):

Physical Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Postal Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Telephone No:(Required)

Email Address:(Required)

Finance Email Address:(Required)

Party representative (if any):

Telephone No:(Required)

Email Address:(Required)

REQUEST FOR COURT ANNEXED MEDIATION

A3. ATTACHMENTS

An agreement to mediate. The parties may draft their own agreement or complete the attached form.

The parties will appoint a mediator or mediators. Should they not be able to appoint a mediator or mediators, AFSA shall make the appointment or appointments.

Description of dispute by the Referring Party. If pleadings or similar documents already exist, these may be attached. The parties may submit any documents upon which they wish to rely.

A4. WHERE A MEDIATOR HAS BEEN AGREED OR APPOINTED DETAILS OF MEDIATOR

Name:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Telephone Number

Email Address

A5. FEE PAYABLE

Fees payable for mediation will be agreed upfront between the mediator, AFSA and the parties.

A6. MEDIATOR’S CERTIFICATE

At the end of the mediation, the mediator will advise AFSA of the outcome of the mediation, and AFSA shall issue a Certificate, on behalf of the mediator, confirming either:

a. that the matter has been settled or
b. that the matter could not be settled.

REFERRING PARTY(Required)

Name

(Duly Authorised)

Date(Required)

Request for Administered Mediation

REQUEST FOR MEDIATION

A1. DETAILS OF REFERRING PARTY

A2. DETAILS OF RESPONDENT / OTHER PARTY

REQUEST FOR COURT ANNEXED MEDIATION

A3. ATTACHMENTS

A4. WHERE A MEDIATOR HAS BEEN AGREED OR APPOINTED DETAILS OF MEDIATOR

A5. FEE PAYABLE

A6. MEDIATOR’S CERTIFICATE

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