Application For Initial Certification As Arbitration Panelist {01-406}

ApplicationforInitialCertification AsArbitrationPanelist (Please print or type) Name Home Address Principal Business Address Business telephone Email Address Attorney State I.D.# Date of Admission to PA Supreme Court PLEASE INDICATE ADDRESS WHERE 1099 TAX FORM SHOULD BE MAILED: Social Security No. I hereby certify that I have been admitted to the Bar of the Court for one year, have tried at least one case in any forum in Pennsylvania, am currently engaged in the active practice of law and maintain my principal office in Philadelphia. I further certify that I attended the Courtapproved Seminar in Arbitration Practices and Procedure on____________________. If my status is changed in regard to any of the above, I will immediately contact the Court of Common Pleas, Arbitration Center, and ask that my name be removed from the certified list of Arbitrators. (a) My practice primarily consists of representing DEFENDANTS. (b) My practice primarily consists of representing PLAINTIFFS. (c) My practice cannot be designated as either (a) or (b). ________________ American LegalNet, Inc. www.FormsWorkFlow.com Are you available to sit as an emergency arbitrator? Yes No Date: Signature: ______________________ Note: See Rule *1302