Free formmsc4.PDF - North Carolina

I.C. Form MSC4 (Rev. 9/01)

NORTH CAROLINA INDUSTRIAL COMMISSION

N.C. Industrial Commission
Mediation Section

4342 Mail Service Center Raleigh, NC 27699-4342
, Plaintiff v. , Defendant , Carrier

I.C. File No(s). Carrier No. County

DESIGNATION OF MEDIATOR

Appearances
Plaintiff'sAttorney Address Telephone Fax ( ( ) ) -

Defendant's Attorney Address

Telephone Fax

( (

) )

-

THIS FORM IS TO BE COMPLETED BY EITHER THE PLAINTIFF OR THE DEFENDANT WITHIN THE TIME SPECIFIED IN THE COMMISSION'S ORDERS AND THE ICMSC RULES.

Pursuant to the Order entered in the above captioned case, referring it to a mediated settlement conference, the parties have selected the mediator named below, who has agreed to serve. Mediator Address
Street Address/P.O. Box City State ZIP Code

Telephone (

)

-

Fax (

)

-

The above named mediator: (check one) Meets the qualifications set forth in ICMSC Rule 8(b). Is qualified to mediate this case by reason of the following training and experience

This the

day of

, 200 . _________________________________
Signature of Plaintiff / Defendant or Representative