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You can type the information directly into this form. When complete, please print, sign and date it, and then mail to:
ADR Center
P.O. Box 65, Hawleyville,
CT 06440

Demand for Arbitration
Date:
Respondent Name:
 
Type of Business or Occupation:
 
Street Address:
 
City, State, & Zip Code:
 
Telephone:
Fax:
Name of Attorney or Representative:
 
Name of Firm or Company:
 
Street Address:
 
City, State, & Zip Code:
 
Telephone:
Fax:
Claimant Name:
 
Type of Business or Occupation:
 
Street Address:
 
City, State, & Zip Code:
 
Telephone:
Fax:
Name of Attorney or Representative:
 
Name of Firm or Company:
 
Street Address:
 
City, State, & Zip Code:
 
Telephone:
Fax:

Claimant(s) is a party to a written contract containing an arbitration agreement, dated , which
provides for arbitration under the rules of American Dispute Resolution Center, Inc. ( ADR Center) and is demanding
arbitration as stated below.

Nature of Dispute:
Amount of Claim or Relief Sought:
Location of Hearing:
(City, State)

Signed: ___________________________________
Title: _____________________________ (Claimant/Representative)
 

In order to initiate the arbitration, Claimant must submit a copy of the contract and two copies of this demand form with
the proper filing fee, which is listed in the rules, to the ADR Center. Send the original of this demand to the Respondent.
Agreed Upon Rules of Procedure: ADR Center Other:
If the Claimant is interested in submitting this matter to mediation, please indicate by marking a check here . The ADR Center will contact the Respondent(s) to determine if they would agree to attempt mediation prior to arbitration.

ADR Center • P.O. Box 65, Hawleyville,
CT 06440
Overnight Mail:
23 Barnabas Rd., Ste 65,
Hawleyville, CT 06440
phone (860) 832-8060 • www.adrcenter.net