Case: Intake - Organization Form

Click this Link to the Individual Form if you are not completing this Intake on behalf of your organization, but only as a primary party involved in the conflict. Please continue if you are completing this form as the executive for the OFFICIAL organization Intake form.

Submission Date

Date Completed*

MonthDayYear

This Intake form is your official organization request for ICC assistance. Please SELECT ONE OPTION that best describes you.*

We are the initiating party in this dispute.We are the respondent in this dispute.

Do you have a conciliation clause specifying that the ICC shall assist in cases of unresolved disputes?*

Yes, we have a valid conciliation clause.No, we have no prior agreement for conciliation.Other

Note: If you indicated YES, we will need a copy of the document that contains your conciliation clause. See the FILE UPLOAD field provided below.

NAME OF YOUR ORGANIZATION*

EMAIL: Please list all organization representatives who should be copied on all EMAIL communication:*

Parties in the conflict must complete the Individual Intake Form

PARTICIPANTS: Please list all organization representatives who will be involved and participating.*

Parties in the conflict must complete the Individual Intake Form

ARBITRATION ONLY: Please list other individuals who may be called as witnesses in this case.

YOUR ORGANIZATION MAILING ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

YOUR NAME*

First NameLast Name

YOUR TITLE/ROLE and in the Organization*

YOUR EMAIL*

Office Phone

Area CodePhone Number

Mobile Phone

Area CodePhone Number

Fax

Area CodePhone Number

Your Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Referred By:

Briefly state your religion and denomination*

Describe how your view of God affects your daily life.*

Describe what impact the Bible has on your thinking and why.*

Are you a member or regular attender of a Christian church?*

YesNoOther

Is your pastor or organization chaplain aware of this conflict?

Do you wish your pastor or chaplain to be a supportive part of the conciliation process?

YesNoOther

If yes, please add your pastor's email address indicating permission to contact.

example@example.com

Note: If you are a pastor directly involved in this conflict, please use your mentor or shepherding pastor's information in the fields below.

Your Pastor's Name

First NameLast Name

Pastor's Email

His Church Name

Denomination

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Has an attorney been assigned to this case?*

YesNoPendingOther

If yes, Who is this attorney officially representing?

Attorney Name

First NameLast Name

Names of Associate Attorneys to be included in correspondence. Include Emails

Law Firm

Attorney E-mail

Attorney Phone Number

Area CodePhone Number

Attorney Fax

Area CodePhone Number

Attorney Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Has legal action been filed? If yes, list date and action, also attach copies of actions in the field below called "VII. Optional File Uploads"

Name of Person with whom you have a dispute*

First NameLast Name

Name of the Organization (if Applicable)

E-mail*

Phone Number*

Area CodePhone Number

Fax

Area CodePhone Number

What steps have you taken to address/ resolve the conflict?*

Please describe the conflict or dispute in 3-4 sentences.*

Are you requesting Mediation, Arbitration or possibly both?*

What are the questions/issues to be answered or resolved through conciliation?*

The claims and/or remedies I seek are (if monetary, please include dollar amount):*

Optional: Attach Files

Browse Files

Your Agreement with the ICC: By submitting this Dispute to the ICC for mediation, arbitration or conciliation we are expressly agreeing to first submit all disputes between you and the ICC over mediation, arbitration or conciliation services provided by the ICC to mediation. If resolution of the dispute between you and the ICC does not result from mediation, the matter shall then be submitted to an independent and objective arbitrator for binding arbitration. The ICC and the parties agree that the mediation and arbitration process will be conducted in accordance with the Rules of Procedure for Christian Conciliation ("Rules"), which can be found at www.iccpeace.com/rules. Consistent with these "Rules," each party to the agreement shall agree to the selection of the arbitrator. The ICC and the parties agree that if there is an impasse in the selection of the arbitrator, the Law Offices of Gerry R. Dagonese, A.P.C. d/b/a “Conflict 2 Peace” shall be designated as the “Administrator” under Rule 2 and shall be asked to provide the name of a qualified person who will serve in that capacity. Consistent with the "Rules," the arbitrator shall issue a written opinion within a reasonable time. The ICC and the parties to this contract agree that these methods shall be the sole remedy for any controversy or claim arising out of this agreement, and they expressly waive their right to a jury trial or to file a lawsuit against one another in any civil court for such disputes, except to enforce a legally binding arbitration decision. The parties to this agreement have had an opportunity to consult legal counsel before signing this agreement.

To authorize this document, type your full name in CAPITAL LETTERS*

Does your full name typed above constitute your organization's legal and authorized signature?*

Yes

ICC Case Intake - Organization Form

I. Your Contact Information

II. Your Faith Background

III. For Church Conflicts

IV. Attorney Information

V. Information about the Conflict

VI. Preliminary Statement of Issues and Remedies

VII. Optional File Uploads

VIII. Agreement

Click Submit to send the ICC Organization Intake Form.