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Request for Mediation Services Form

Dear Member,

This form acts as a formal request to access the pro-bono mediation services as agreed between the CBAA and the Institute of Arbitrators and Mediators Australia (IAMA).

The Mediation process is to be requested as part of a formal Grievance Process. Please note the following conditions before proceeding.

•The Service consists of approximately 3 hours of mediation services from an accredited IAMA mediator. Any extension of the services is to be arranged between the Station and the Mediator, at specified rates which are discounted for CBAA Members ($200 plus GST).

•The person requesting the Service is an authorised representative of the Station (President or appointed delegate).

•All parties to the mediation have agreed to participate in the mediation process.

•The Station has taken steps to follow their Grievance processes prior to applying for mediation services.

When you press 'Submit' at the completion of this form it will be directed confidentially to the CBAA Membership Manager who will contact you.

Address of Station *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Station Name *
Call Sign *
Name of Applicant * First Last
Email *
Phone Number *
1. What are the names of the parties to the dispute? *
2. Briefly state the nature of the dispute (less than 500 words). *
3. Give a description of your station (number of volunteers, Community of Interest, role it plays in the community, relevant historical facts) *
4. Have all parties to the dispute agreed to the mediation? *
Yes No
Do Not Fill This Out

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