Google Play Store Mediation Scheme Application Form

Google Play Store Mediation Scheme Application Form

To be completed by an Applicant Business User.

Google Play Store Mediation Scheme

Application form
1. Date of submission
Please note that submissions received by CEDR before 17:00 (GMT/BST) on a business day will be treated as received on the date of the email. All submissions received after 17:00 (GMT/BST) will be treated as received on the next business day.
Date of submission (insert today's date)

DayMonthYear
2. Business User Information
Business User/Company Name*
Address*

Street Address

Street Address Line 2

TownCountry

Post Code
Telephone

Area CodePhone Number
Please provide contact details of the person attending the mediation*

First NameLast Name
Email*
example@example.com

3. Dispute value

Please indicate the value of this dispute, if applicable. Claim values should be calculated by the higher of either the potential claim or counterclaim but not both combined.
Dispute value

Up to €25,000€25,001-€75,000€75,001 - €125,000€125,001 - €250,000€250,001 - €500,000In excess of €500,000
4. Proposed mediation dates

Please specify the date or dates on which you are available to mediate from 15-45 business days from the date you submit this application, in order of preference. Please only provide dates when you are certain you are available, as they will be used by CEDR to appoint a mediator and arrange the mediation.
Date(s):
5. Issues in dispute

Please provide (in brief) a summary of the dispute, and what you would like the mediation to achieve (you can provide more detailed information in a case summary before the mediation).
Dispute summary*

0/500
6. Party A/Legal representation (if applicable)
Main contact

First NameLast Name
Firm name
Email
example@example.com
Country
Phone Number

Area CodePhone Number

7. Party A - Agreement to proceed
Once this application form is submitted, CEDR will then contact Google providing a copy of this Application Form, as completed by you, to confirm consent to mediate and to check availability for mediation dates. Once consent is received from Google, CEDR will provide both parties with the appointed mediator and the date of the mediation.

Google Play Store Mediation Scheme