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matter
referring party
First Name(s)
Surname
Registration No (if juristic)
Address Line 1
Address Line 2
Address Line 3
Postal Code
Mobile Number
Email Address
VAT Number
claimant representative
First Name(s)
Surname
Telephone (W)
Email Address
other party
First Name(s)
Surname
Registration No (if juristic)
Address Line 1
Address Line 2
Address Line 3
Postal Code
Mobile Number
Email Address
VAT Number
other party representative
First Name(s)
Surname
Telephone (W)
Email Address
mediation
Admin Fee Payment Confirmation
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Written Agreement to Mediate
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Pleadings or Similar Documents
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referring party mediator
First Name(s)
Surname
Address Line 1
Address Line 2
Address Line 3
Postal Code
Telephone (W)
Email Address
Surname
REQUEST FOR MEDIATION The Registrar
AFSA Secretariat
First Floor, Grindrod Tower
8A Protea Place, Sandton

PO Box 653007, Benmore, 2010
Docex 143 Randburg

The Referring Party is required to complete the form below insofar as the information required is available to it. Upon submission, the
Referring Party will receive an email confirming receipt of the request.

 
A1. DETAILS OF REFERRING PARTY
Name: «First Name(s)» «Surname»
Registration No (if a juristic person): «Registration No (if juristic)»
Address: «Address Line 1» «Address Line 2» «Address Line 3» «Postal Code»
Telephone No: «Mobile Number»
Email Address: «Email Address»
VAT Number: «VAT Number»
Legal Representative (if any): «First Name(s)» «Surname»
Telephone No: «Telephone (W)»
Email address: «Email Address»
 
A2. DETAILS OF RESPONDENT / OTHER PARTY
Name: «First Name(s)» «Surname»
Registration No (if a juristic person): «Registration No (if juristic)»
Address: «Address Line 1» «Address Line 2» «Address Line 3» «Postal Code»
Telephone No: «Mobile Number»
Email Address: «Email Address»
VAT Number: «VAT Number»
Legal Representative (if any): «First Name(s)» «Surname»
Telephone No: «Telephone (W)»
Email address: «Email Address»
 
A3. ATTACHMENTS
(a)  A copy of the EFT payment confirmation showing the Referring Party has paid the administration fee of R10,000 plus VAT required to administer the mediation, which fee is non-refundable. «Admin Fee Payment Confirmation»
 
(b)  Written agreement in which the parties agree to mediation  «Written Agreement to Mediate»

(c)  Description of dispute. If pleadings or similar documents already exist, these may be attached.  If no pleadings exist, the Referring Party is required to reflect, in a separate document, the particulars of the dispute, alternatively its assertion to which the respondent may react. Any key source documents relevant to the dispute may also be attached. «Pleadings or Similar Documents»
 
A4. WHERE A MEDIATOR HAS BEEN AGREED OR APPOINTED
DETAILS OF MEDIATOR
Name: «First Name(s)» «Surname»
Address: «Address Line 1» «Address Line 2» «Address Line 3» «Postal Code»
Telephone No: «Telephone (W)»
Email Address: «Email Address»
 
A5. WHERE A MEDIATOR HAS NOT BEEN AGREED OR APPOINTED
The Referring Party requires the appointment of a mediator by AFSA with the following seniority.
Seniority (in professional practise) Fee (tick applicable)
15+ years R40 000.00 (plus VAT)  
Years 10 to 15 R30 000.00 (plus VAT)  
Years 5 to 10 R20 000.00 (plus VAT)  
The Referring Party undertakes to pay half of the fee payable for the mediator when the mediator is appointed, which fee is an all-inclusive fee for all attendances on the mediation and includes compensation for all preparation, one pre-mediation meeting (if necessary) and one day for the mediation proceedings.
 


 
A6. MEDIATOR'S CERTIFICATE
The Referring Party agrees/does not agree* to the Mediator completing Part 2 to the Mediator's Certificate at the end of the mediation.  (The wording of the Mediator's Certificate appears at Annexure 3 to the AFSA Mediation Rules)




_________________________________________
REFERRING PARTY
Name:  «First Name(s)» «Surname»
(Duly Authorised)
Date: «SYSTEM.Date_CurrentDay | HIDEONPREVIEW»/«SYSTEM.Date_CurrentMonth | HIDEONPREVIEW»/«SYSTEM.Date_CurrentYear | HIDEONPREVIEW»
«MATTER.MatterID | HIDEONPREVIEW»
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