ALLAHABAD HIGH COURT MEDIATION & CONCILIATION CENTRE

FORM – I

PRE-LITIGATION MEDIATION APPLICATION FORM

DETAILS OF PARTIES :

1. Name of applicant(s):

2. Address of applicant:

3. Contact details of Applicant: Telephone No. ______ Mobile _________ E-mail ID : ___

4. Name and Address of opposite party/ person(s) with whom pre-litigation Mediation is sought for: ………………………………………………………………………..

5. Contact details of opposite party: Telephone No. ______ Mobile ____ E-mail ID : ___

6. Enclosure: Self Attested copy of Aadhaar Card of the applicant.

DETAILS OF DISPUTE

1. Nature of dispute :

2. Value/Quantum of claim :

3. Territorial Jurisdiction of the competent court :

4. Brief background of dispute :

5. Additional points of relevance :

6. Details of documents filed alongwith the Application in support of claim:

Date:         Name and signature of Applicant

Declaration

I, the above mentioned applicant, do hereby solemnly affirm and declare as under:

1. That I desire to get my dispute resolved through Mediation and would abide by the terms of settlement to be reached between the parties.

2. That I also undertake to abide by the terms and conditions of Pre-litigation Mediation.

3. That I have neither initiated any civil or criminal proceedings in the present matter, nor I am aware of any proceedings pending in any court of law in respect of the matter in which I desire to get my dispute resolved through Pre-litigation Mediation.

(Signature of Applicant)