Civil Mediator Application

SUPERIOR COURT OF CALIFORNIA ~ COUNTY OF FRESNO ALTERNATIVE DISPUTE RESOLUTION DEPARTMENT MEDIATOR PANEL APPLICATION Name___________________________________________________________ Address_________________________________________________________ City_____________________________________________________________ State________________________________________ Zip_________________ Phone_________________________ Fax______________________________ E-mail___________________________________________________________ Cell Phone Number (optional and for internal use only) _____________________________ Occupation____________________________ How Long__________________ Employer_________________________________________________________ Address__________________________________________________________ City_____________________________________________________________ State_________________________________________Zip_________________ Phone__________________________ Fax______________________________ E-mail___________________________________________________________ College Attended_______________________________ Degree_____________ Graduate or Law School Attended_____________________________________ Degree or Bar #________________________________Date Awarded________ Mediation Training: Include institutions, programs and dates. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Mediation Experience: Include number of mediations conducted in past 3 years. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com MEDIATOR APPLICATION PAGE TWO Professional Affiliations with Dispute Resolution Organizations; list dates. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Areas of Expertise: Business Employment Healthcare Malpractice Real Estate ______ ______ ______ ______ ______ Construction Environment Insurance Personal Injury Other ______ ______ ______ ______ ______ Foreign Languages in which you are capable of conducting a mediation. ________________________________________________________________ ________________________________________________________________ Insurance Carrier__________________________________________________ Address _________________________________________________________ City _____________________________State _________Zip _______________ Phone ___________________________________________________________ Current Reimbursement Rate ________________________________________ Other Relevant Information __________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Signature below certifies that all of the above information is true and correct and that applicant agrees to adhere to Court Standards of Professional Conduct. Signature ____________________________ Date _______________________ Return this form and your personal narrative to: Mari Henson, ADR Administrator B.F SISK Courthouse 1130 "O" Street Fresno, CA 93724-0002 Phone: (559) 457-1908 ~ Fax: (559) 457-1691 mhenson@fresno.courts.ca.gov www.FormsWorkFlow.com