REQUEST FOR MEDIATION

In the matter of _________________________________ v. _______________________________

                                     Complainant                                                     Respondent

Mediation is requested with the above-named disputant prior to a hearing of this dispute by the Professional Standards Committee of the Board.  There is due, unpaid and owing to me from the above-named Respondent the sum of $__________________.  My claim is predicated upon the statement attached, marked Exhibit 1 and incorporated by reference into this Request.

Property address:_______________________________________________________________________

Date of title transfer:_____________________________


_____________________________                                                                                                                                        
REALTOR Principal/Broker Signature

Name (type/print): ____________________________________________________________________                                 

Address: ____________________________________________________________________________                                                                                                                       
Phone: _________________________________________________                   

This form must be submitted with the Request and Agreement to Arbitrate form to the Professional Standards Department of CABOR.