Canova Law & Mediation

217 E. Dickson St. Suite 106H (Top floor)
Fayetteville, AR 72701-4283

(479) 442-5800

Please provide the information below to provide information to allow us to contact you and the other mediation participant so that we can get your Mediation on our calendar. If you have a preference as to how we contact you, please let us know in your description of what you want addressed in your mediation.

All information provided will be confidential and not released outside our organization.

Contact information: Contact 1

Prefix

First name *

Middle name

Last name *

Date of birth

Company

Emails

Address *

Type

Upon submission, a copy of this form will be sent to the primary email.

PrimaryDefault email false

Add email

Addresses

Street address

Country

City

State/Region

Province/Region

Zip/Postal code

Address type

PrimaryDefault address false

Add address

Phone numbers

Phone number

Type

Primary

Add phone number

Give us a brief description of the issues you wish to resolve in mediation.

How do you prefer we contact you?

Contact information: Other mediation participant's contact information

Prefix

First name *

Middle name

Last name *

Date of birth

Company

Emails

Address *

Type

PrimaryDefault email false

Add email

Addresses

Street address

Country

City

State/Region

Province/Region

Zip/Postal code

Address type

PrimaryDefault address false

Add address

Phone numbers

Phone number

Type

Primary

Add phone number

Are you currently represented by an attorney?

No.

Yes.

If so, please provide the name and phone number of your attorney.

Is the other participant represented by an attorney?

Yes.

If so, please provide the name and phone number of his/her attorney.

No.

Unsure.