Designation Form Of Mediator printable pdf download

Designation Form Of Mediator

I.C. Form MSC4 (Rev. 9/01)

NORTH CAROLINA INDUSTRIAL COMMISSION

N.C. Industrial Commission

Mediation Section

I.C. File No(s).

4342 Mail Service Center

Carrier No.

County

27699-4342

Raleigh, NC

, Plaintiff

DESIGNATION OF MEDIATOR

, Defendant

, Carrier

Appearances

Plaintiff’sAttorney

Telephone

(

)

Address

Fax

(

)

Defendant’s Attorney

Telephone

(

)

Address

Fax

(

)

THIS FORM IS TO BE COMPLETED BY EITHER THE PLAINTIFF OR THE DEFENDANT WITHIN THE TIME SPECIFIED IN THE

COMMISSION’S ORDERS AND THE ICMSC RULES.

Pursuant to the Order entered in the above captioned case, referring it to a mediated settlement

conference, the parties have selected the mediator named below, who has agreed to serve.

Mediator

Telephone (

)

Fax (

)

Address

Street Address/P.O. Box

City

State

ZIP Code

The above named mediator: (check one)

Meets the qualifications set forth in ICMSC Rule 8(b).

Is qualified to mediate this case by reason of the following training and experience

This the

day of

_________________________________

Signature of Plaintiff / Defendant or Representative

Designation Form Of Mediator

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