T.C.

…… Mediation Bureau

MEDIATION APPLICATION FORM

APPLICATION NUMBER: …./….

REFERENCES: …/…/…

APPLICANT INFORMATION

TC ID No.:

Name Surname:

Job:

Education Status:

Address:

Deputy:

COUNTERPARTY INFORMATION

TC ID No.

Name Surname:

Job:

Education Status:

Address:

Deputy:

REFERENCES

Case Type:

Does The Counterparty Have Information :

Application Subject Application Status:

Statements regarding the subject:

I declare that I know that the mediator will be selected by the parties unless another procedure is agreed, that I have read and understood all the explanations contained in the application petition, that I have fully submitted all the information I have on the subject of the application, and that I request and request that this application be processed.

Applicant

Signature