Here you can download the model for the request for mediation

REQUEST FOR MEDIATION

CEPANI npo
Belgian Center for Arbitration and Mediation
Rue des Sols 8
1000 BRUSSELS

Notifies:

Claimant:
(name, first name and complete denomination, quality, address, telephone and fax number, e-mail address, VAT-number)

having as counsel:

Hereinafter named “Claimant”

that it introduces a request for Mediation following the rules of mediation of Cepani, as a result of and until the resolution of the dispute between Claimant and:

Respondent:
(name, first name and complete denomination, quality, address, telephone and fax number, e-mail address, VAT-number)

having as counsel:

Hereinafter named “Respondent” 

* * *

Following the Rules of Cepina in force as from the 1st of January 2005.

Subject to all rights and without any prejudicial recognition.

* * *

 The Request for Mediation is based on the following elements:

I. A RECITAL OF THE NATURE AND CIRCUMSTANCES OF THE DISPUTE GIVING RISE TO THE CLAIM

II. A STATEMENT OF THE RELIEF SOUGHT, A SUMMARY OF THE GROUNDS FOR THE CLAIM, AND IF POSSIBLE, A FINANCIAL ESTIMATE OF THE AMOUNT OF THE CLAIM

III. LANGUAGE OF THE MEDIATION

IV. SEAT OF THE MEDIATION

V. APPLICABLE RULES OF LAW

(date)


(Claimant)
 (name + quality of the representative

FOR (claimant) 
its counsel
(First Name, Name)