Alternative Dispute Resolution (ADR) Family Law Mediation Panel Application {PFL-40}

SUPERIOR COURT OF CALIFORNIA COUNTY OF FRESNO ALTERNATIVE DISPUTE RESOLUTION (ADR) FAMILY LAW MEDIATION PANEL APPLICATION Name: Address: City: State: Phone: E-mail: Cell Phone Number (optional and for internal use only): Occupation: Employer: Address: City: State: Phone: E-mail: College Attended: Degree: Graduate or Law School Attended: Degree or Bar #: Zip Code: FAX: Zip Code: FAX: Date Awarded: (Please attach a copy of your CV) Mediation Training (Include institutions, programs and dates): Mediation Experience (Include number of mediations conducted in the past 3 years): PFL-40 E05-16 OPTIONAL Family Law Mediator Panel Application Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com SUPERIOR COURT OF CALIFORNIA COUNTY OF FRESNO ALTERNATIVE DISPUTE RESOLUTION (ADR) FAMILY LAW MEDIATION PANEL APPLICATION Professional Affiliations with Dispute Resolution Organizations; list dates: Years of Practice in Family Law: Foreign Languages in which you are capable of conducting a mediation: Insurance Carrier: Address: City: Phone: Insurance Limits of Liability: (Please attach a copy of your E&O Insurance Declarations Page) State: Zip: Current Hourly Rate: Other Relevant Information: Signature below certifies that all of the above information is true and correct and that the applicant agrees to adhere to Court Standards of Professional Conduct. Signature Return this form to: Date 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 PFL-40 E05-16 OPTIONAL Family Law Mediator Panel Application Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com