Please select topic area below:

Case Referral Problem Suggestion Praise

 Other:

Enter your comments or a summary of your case in the space provided below. (Please include other disputing party's contact information.):

Tell us how to get in touch with you:

NAME
E-MAIL
TELEPHONE AT TELECONF. SITE
CELL NUMBER
FAX
COMPANY
ADDRESS
CITY
STATE/ PROVINCE
POSTAL CODE
COUNTRY

 

If you would like to resolve this matter via video-conference mediation, please complete the following:

TYPE OF INTERNET SERVICE  T1 SDSL ADSL Cable Modem Dial-Up Connection Other: Specify Below

Other: 

COMPUTER/OPERATING SYSTEM    PC/Windows 95 PC/Windows 98 PC/Windows 2000 PC/Windows NT PC/Windows XP Home PC/Windows XP Pro Other: Specify below

  Other: 

TYPE PROCESSOR Pentium 4 Pentium 3 Pentium 2 Other: Specify below

                                        Other:  

PROCESSOR SPEED (in MHZ) 

AMOUNT OF RAM     

IS YOUR COMPUTER ON A MULTI-PARTY NETWORK/SERVER?

Important: If the answer  to the above question is yes, you must be able adjust firewall and popup protection to enable video-conferencing.  Please secure cooperation of your network administrator assist you in testing hardware and software.  

NUMBER OF INDIVIDUALS AT YOUR SITE TO PARTICIPATE IN VIDEO-CONFERENCING MEDIATION 

VIDEO-CONFERENCING HARDWARE REQUIREMENTS (If one individual in your party, put "webcam/headset" below; if more than one individual participating and you have speaker(s) with your computer, put "webcam/microphone" below; If you have or are securing your own equipment, put "none" below.