We are pleased that you have contacted us to inquire about our mediation/arbitration services.  Please print this form, fill it in and fax or mail it to us.  We will telephone the person identified below as the Requestor if further information is required.

Please indicate which attorney you would like to mediate/arbitrate your matter.

     [   ]  Chris P. Lavdiotis        [   ]   Bruce P. Loper  

     [   ]  Ralph A. Lombardi       [   ]  Matthew S. Conant

     [   ]  Peter O. Glaessner

Nature of Service Requested:    [    ] Mediation   [    ] Arbitration

Title of  dispute:  ____                                                               

Court.:                                         Case No.:             _________   

Deadline:                                      Trial Date:                              

Prior Mediation/Arbitration?  [    ] Yes                 [    ] No

Nature of Dispute:                                                                     

Requestor’s name:   _________________________________________

Requestor’s telephone no.:   __________________________________

Requestor’s relationship to the parties: _________________________

        _____________________________________________________

[    ]    Additional Parties/Information Attached

MEDIATION AND ARBITRATION SERVICES REQUEST FORM
THIS FORM IS FOR INFORMATIONAL PURPOSES. IT IS NOT A
CONTRACT FOR SERVICES AND NEITHER THE REQUESTOR NOR
LOMBARDI, LOPER & CONANT SHALL REPRESENT THAT IT
CONSTITUTES A CONTRACT OF ENGAGEMENT OR A RECOGNITION OF
AN OBLIGATION TO PAY FOR SERVICES.