Tribal Mediation Intake Form

Tribe

Please provide the name of the tribe submitting a request for mediation:

Name of person requesting mediation:

Email of person requesting services

Name of primary contact at tribe

Primary contact email

Primary contact phone

Description of issue

Please provide a brief description of the issue as you understand it:

Other potential stakeholders

Please provide the names of other stakeholders you believe should be engaged in this process:

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