Dispute Resolution Commission Complaint {DRC-5}

DISPUTE RESOLUTION COMMISSION STATE OF NORTH CAROLINA COMPLAINT INSTRUCTIONS: Please type or print and mail along with any attachments to the N. C. Dispute Resolution Commission, P. O. Box 2448, Raleigh, NC 27602. Name And Address Of Complainant Telephone No. (Work) Telephone No. (Home) 1. Name of the mediator, mediation trainer or mediation training program that is the subject of your complaint. (If your complaint is against a trainer, indicate the training program with which he/she is affiliated.): 2. If your complaint concerns a mediator, identify the dispute or court case which the mediator was selected or appointed to mediate and from which your complaint arose. (If filed in court, please provide the case name and number assigned to your litigation by the Clerk. If the dispute in which you are or were involved has not been filed as a court case or assigned a number by the Clerk, list the principal parties involved): 3. If a mediation conference was held, give the date(s) on which it was conducted and the location of the conference: 4. If your complaint involves a mediation trainer or training program, indicate the dates on which you attended training and the location where the training was held: 5. In the space below, please describe your complaint against the mediator, mediation trainer or training program named above and indicate all facts upon which your complaint is based. (If necessary, add additional pages.): DRC-5, New 7/99 1999 Administrative Office of the Courts (Over) <<<<<<<<<********>>>>>>>>>>>>> 2 Description of Complaint (continued from side one) 6. Provide below names of all individuals who have knowledge of your above complaint and indicate how they may be contacted. (Add additional pages if necessary.): Name And Address Of Individual 1 Name And Address Of Individual 2Daytime Telephone No. Daytime Telephone No. 7. Please attach to this completed form copies of any correspondence or other documents which support your complaint. I understand and agree: 1) that I am providing this material to representatives of the Dispute Resolution Commission (DRC) to enable them to investigate the alleged misconduct of the mediator, mediation trainer or mediation training program that is the subject of this Complaint; 2) that those representatives may contact me or any of the individuals whose names I have disclosed in connection with this Complaint in an effort to obtain additional information; 3) that this Complaint will be treated as confidential except that any evidence resulting from the DRCs investigation of this matter may be shared with the mediator, mediation trainer or mediation training program that is the subject of this Complaint; 4) that I will cooperate with the DRC during its investigation and furnish all pertinent information and records in my possession concerning the alleged misconduct; 5) that if a public hearing is conducted in this matter, that I will appear at that hearing and offer testimony or otherwise give evidence in support of this complaint; 6) that if the Commission finds that the mediator, mediation trainer or mediation training program is not guilty of the misconduct alleged in this Complaint and then further finds that this Complaint was made with intent to harass or vex its subject, that I may be liable for the costs associated with the hearing; and 7) that I have given true, accurate and complete information on this form to the best of my knowledge. Date SWORN AND SUBSCRIBED TO BEFORE ME Date Signature Signature Of ComplainantTitle Of Person Authorized To Administer Oaths Name Of Complainant (Type Or Print)Date Commission Expires SEAL DRC-5, Side Two, New 7/99 1999 Administrative Office of the Courts