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REPUBLIC OF SOUTH AFRICA
FORM 3
(Rules 78 (1))
APPLICATION FOR REFERRAL TO MEDIATION
(After commencement of litigation)
COURT: ……………………………………………………………………………………..
FILE NO: ………………………..
PARTIES:
………………………………………………………………………………………………………………………….. Claimant
And
………………………………………………………………………………………………………………………….. Respondent
(To be completed by party(ies) /mediation clerk)
1.
I the undersigned, the Claimant/Respondent or Representative, apply for referral to mediation of the matter under
Court Case No ……………………………………………………
2.
PARTICULARS OF CLAIMANT:
Surname/Name
……………………………………………………………………………………………………………
First Names
……………………………………………………………………………………………………………
Residential address
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
Business Address
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
3.
Postal Address
……………………………………………………………………………………………………………
Telephone
…………………………………….
Cellular phone …………………….……….………………
Fax no
……………………………………
Email ………………..………………………………………..
PARTICULARS OF RESPONDENT:
Surname/Name
……………………………………………………………………………………………………………
First Names
……………………………………………………………………………………………………………
Residential address
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
Business Address
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
Postal Address
……………………………………………………………………………………………………………
Telephone
…………………………………….
Cellular phone …………………….……….………………
Fax no
……………………………………
Email ………………..………………………………………..
J……
4.
Summary of claim/defence
……………………………………………………………………………………………………………………………………
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Signed at …………………………………………………..… on this ………….day of …………………………………….
______________________________
CLAIMANT/RESPONDENT
(If more than one claimant or respondent separate annexures should be used to provide particulars of further claimants
and/or respondents)
2