Independent Conciliation Service for County Court Small Claims Track Disputes

Independent Conciliation Service for County Court Small Claims Track Disputes

Application Form

Application Form for CEDR Conciliation

The CEDR Conciliation Scheme provides an opportunity for customers to resolve disputes with business through dialogue facilitated by a professional CEDR Accredited Mediator. This Scheme is available to users who consent to using a Conciliator to resolve the dispute that has arisen.

The Centre for Effective Dispute Resolution (CEDR Services Ltd) is a Not-for-Profit organisation approved to provide dispute resolution services. CEDR will conciliate disputes that are eligible. We will only decline to assist if the use of these third parties would seriously impair the effectiveness of the service offered to businesses and their customers.

CEDR is not responsible for paying compensation or making a financial award. If your dispute is resolved via the conciliation process and a payment has been agreed, then this is sorted out between the parties. However, both parties are equally responsible for paying CEDR’s fees.

How do I make a complaint and what happens next?
- Upon receipt of your completed form CEDR will acknowledge receipt with 7 working days
- Full details of the conciliation procedure and guidance notes are available on the CEDR website
- If you require additional guidance or assistance, please contact the CEDR office via email at applications@cedr.com
Please answer all sections on this form to the best of your knowledge as any missing information may cause delays with the process.
Application Form for CEDR Conciliation
1. About you (Claimant)

Please provide your full contact details.
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

TownCounty

Post Code
Email*
example@example.com
Telephone

Area CodePhone Number
Please select the County Court that has referred you to CEDR:*
2. Representation
Are you represented by somebody else?

YesNo
If someone is applying on your behalf, please provide their details here and sign the declaration.
Name

First NameLast Name
Organisation
If applicable
Address

Street Address

Street Address Line 2

TownCounty

Post Code
Email
example@example.com
Telephone

Area CodePhone Number
To be signed by the applicant named in section 1. I hereby give my authority for the above named person to represent me:

Clear
Type your name

First NameLast Name
Date

DayMonthYear

3. Respondent details

Please give the full trading name of the Business that you are in dispute with.
Company name*
Contact name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
4. Dispute details
4.1 Please provide a summary of your dispute.
4.2 Please tell us what had gone wrong.
5. Desired Outcome
Please detail the outcome/s you are seeking from the conciliation process
Please confirm the amount claimed*

5. Declarations

Please read the following statements carefully and make sure that you understand your responsibilities before signing this application form.
- I/We believe that the facts stated in this application and claim form are true and my claim does not exceed £10,000 plus VAT.
- I/We have read and understood the Service Rules (accessible here).
- I/We agree and understand that the conciliator’s recommendations are not binding unless written down and signed by both parties in the agreement.
- I/We have tried to resolve this matter through the company’s internal complaint procedure and have read and understood the guidance provided in this application form.
- I/We also understand that conciliation is a confidential process in which the Conciliator as a neutral third party assists parties in working towards a negotiated agreement, with the parties in ultimate control of decision to settle and the terms of resolution.
- I/We declare that I/we am/are authorised to sign this form as the customer and understand that it is my/our responsibility to ensure that I/we understand the process and will seek guidance from CEDR if required.
- I/We understand that a copy of this application form will be given to the Business.
- I/We understand that any other information given to the Conciliator during the conciliation will be confidential unless I/We permit the Conciliator to give information to the other party.
- I/We accept that the proceedings are confidential and without prejudice.
- I/We understand that the Conciliator does not give legal advice.
- I/We also understand the Conciliator does not act as a judge or arbitrator. However, should the parties be unable to reach an agreement between them, the conciliator may recommend a solution to the dispute.
- I/We believe that the facts stated in this application and claim form are true.
Signature*

Clear
Type your name*

First NameLast Name
Date*

DayMonthYear

6. Payment

Small Claims Application £200 Application fee + VAT

£200.00 Quantity

Subtotal

£0.00

Tax

£0.00

Total

£0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

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Independent Conciliation Service for County Court Small Claims Track Disputes

Application Form for CEDR Conciliation

How do I make a complaint and what happens next?

Application Form for CEDR Conciliation

1. About you (Claimant)

2. Representation

3. Respondent details

4. Dispute details

5. Desired Outcome

5. Declarations

6. Payment