MEDIATION SUBMITTAL FORM

Submitting the following information at this time will help us to process your referral quickly and efficiently. Please e-mail a proof of service to us, noting which counsel is representing the respective parties, and a caption page. Doing so will enable us to be aware of the identity of all of the parties to the dispute as well as the court¹s case number, so that we may complete a conflicts check, prepare a confirming letter and copy any necessary Court ADR Administrator. We also like to have e-mail addresses for all counsel of record for scheduling the session.

For a case submitted to Frederick Carr, E-mail to fredcarr@carrvenneradr.com

For a case submitted to Charlotte Venner, E-mail to venneradr@msn.com

*Fred Carr and Charlotte M. Venner are individual, sole mediation practitioners, and are not a partnership or other form of legal association.

This form is sent through a secure server. You may also print it out and fax it to us at 415-388-1036.
Note: All fields marked with an asterisk (*) are required. Thank you.

With which Mediator would you like to work? *	Frederick Carr Charlotte Venner
Type of Case / Dispute:
Case Name: *
Your principal / insured / client is a: *	Plaintiff Defendant Cross/Defendant Other (Please Describe below)
Other Description:
Submitting Atty. or Party: *
Your US Mailing Address:
Submitting Insurance Carrier:
Your E-Mail: *
Your Phone Number: *
Your Fax:
Other counsel's E-mail address (eg. Name : E-mail address):

This form is sent through a secure server.

FREDERICK J. CARR, ESQ. CHARLOTTE M. VENNER, ESQ. (415) 388-0905

MEDIATION SUBMITTAL FORM

FREDERICK J. CARR, ESQ.
CHARLOTTE M. VENNER, ESQ.
(415) 388-0905