Please Complete this Instant E-Mail Form:

CONFLICT RESOLUTION AND INFORMATION REQUEST FORM

CONTACT INFORMATION
Name:
City:
Province/State:
Email Address:
Phone:
Fax:
(don't forget to include your area code)

WHAT KIND OF CONFLICT IS IT?
	BUSINESS TO BUSINESS		BUSINESS/CONSUMER
	EMPLOYMENT		FAMILY
	SEPARATION/DIVORCE		CUSTODY & ACCESS
	NEIGHBOURHOOD		ORGANIZATION: INTERNAL CONFLICT
	CHURCH CONFLICT		OTHER

I AM INTERESTED IN:
	CONCILIATION		MEDIATION
	ARBITRATION		CONSULTATION
	MEETING FACILITATION		CONFLICT MANAGEMENT
	INFORMATION		PRESENTATION
Do you have the authority to resolve the conflict? Yes No N/A

PLEASE TELL US ABOUT THE CONFLICT FROM YOUR PERSPECTIVE

Problems with the form ?? Email: mediationcentre@rogers.com or Phone: (519) 633-4423