Housing and Residence Life

Name of Party Requesting Mediation:

Banner I.D. Number:

Residence Hall/Apartment:

Room Number:

Email:

Phone:

Parties Involved

Party 1

Party 1 (Name):

Party 1 (Phone):

Party 1 (Email):

Party 2

Party 2 (Name):

Party 2 (Phone):

Party 2 (Email):

Party 3

Party 3 (Name):

Party 3 (Phone):

Party 3 (Email):

Party 4

Party 4 (Name):

Party 4 (Phone):

Party 4 (Email):

Party 5

Party 5 (Name):

Party 5 (Phone):

Party 5 (Email):

Party 6

Party 6 (Name):

Party 6 (Phone):

Party 6 (Email):

Nature of relation with those in dispute with (ex: roommate, suitemate, apartment-mate etc.):

Nature of dispute:

Have you made an effort to talk with the person(s) you are in dispute with?

Yes

No

Have any actions been taken in an attempt to resolve dispute?

Yes

No

If yes, list: