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Approved, SCAO

CIVIL MEDIATOR APPLICATION To be eligible to serve as a general civil mediator, you must meet the training and experience criteria specified either in MCR 2.411(F)(2) or in the SCAO Mediation Training Standards and Procedures pursuant to MCR 2.411(F)(3). Service as a case evaluator under MCR 2.403 does not constitute a qualification for serving as a mediator. Refer to the Mediation Training Standards and Procedures for further information about minimum qualifications. Note: Except for Part B, the information provided in this application is available to the public for inspection. Please type or print neatly.
1. Full name (first, middle initial, last) 3. Address where you can be contacted 4. Telephone no. 5. Fax no. 6. E-mail address 2. Bar no. if applicable

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Part A: General Civil Mediator Qualifications Complete item 7 and either item 8, 9, 10, 11, or 12 as appropriate.
7. 8. Is this a new application? renewal? If renewing, complete item 12 and attach a copy of your original application.

Qualification through State Court Administrative Office (SCAO) Approved Training a. SCAO-approved training completed on
Date

. Attach copy of certificate.

Trainer: b. Juris doctorate. Attach copy of diploma if not a licensed attorney. Graduate degree in conflict resolution. Attach copy of diploma. 40 hours of mediation, observation, or role-playing experience for more than 2 years before applying. Detail below. Complete
on separate page if needed.

c. Observed two general civil mediation proceedings. Specify dates and mediator names and attach verification. Do not provide party names.

d. Conducted one general civil mediation to conclusion. Specify date and name of mediator serving as supervisor and attach verification. Do
not provide party names.

9.

Qualification by Community Dispute Resolution Program (CDRP) Training a. Michigan CDRP training completed on
Date

.

Attach copy of certificate.

Trainer: If the training was completed more than 2 years before applying, applicant must have completed 8 hours of advance mediation training in the 2 years before applying. Specify type of training, dates, and trainers, and attach copy of certificate.

continued on page 2
MC 281a (3/08)

CIVIL MEDIATOR APPLICATION, Page 1 of 4

MCR 2.411(E)

Civil Mediator Application, continued from page 1

Part A: General Civil Mediator Qualifications (continued)
9. b. Observed two general civil mediation proceedings. Specify dates and mediator names and attach verification. Do not provide party names.

c. Conducted one general civil mediation to conclusion. Specify date and name of mediator serving as supervisor and attach verification. Do
not provide party names.

d. If not an attorney or a person holding a juris doctorate or graduate degree in conflict resolution, applicant must have mediated at least 40 hours or 18 cases in the 2 years before applying. Detail below. Complete on separate page if needed. Do not provide party names.

e.

As a non-Michigan licensed lawyer/nonlawyer, completed on
Date

,

a 6-hour program addressing basic Michigan laws, rules, and guidelines governing civil actions. Instructor: 10. Qualification by Training Outside of Michigan a. Completed a comprehensive training course of at least 40 hours designed for general civil case mediation. Attached are: (1) a certificate of completed training, (2) a copy of the training agenda, (3) the name of the trainer, (4) the date of the training, and (5) the dates of attendance. b. If the training was completed more than 2 years before applying, applicant must have completed at least 8 hours of advanced mediation training in the 2 years before applying. Specify type of training, dates, and trainers, and attach copy of certificate.

c. Observed two general civil mediation proceedings. Specify dates and mediator names and attach verification. Do not provide party names.

d. Conducted one general civil mediation to conclusion. Specify date and name of mediator serving as supervisor and attach verification. Do
not provide party names.

e. If not an attorney or a person holding a juris doctorate or graduate degree in conflict resolution, applicant must have mediated at least 40 hours or 18 cases in the 2 years before applying. Detail below. Complete on separate page if needed. Do not provide party names.

f.

As a non-Michigan licensed lawyer/nonlawyer, completed on
Date

,

a 6-hour program addressing basic Michigan laws, rules, and guidelines governing civil actions. Instructor: continued on page 3
MC 281a (3/08)

CIVIL MEDIATOR APPLICATION, Page 2 of 4

MCR 2.411(E)

Civil Mediator Application, continued from page 2

Part A: General Civil Mediator Qualifications (continued)
11. Other Qualification Complete items 11a or 11b and 11c through 11e. a. Voluntary Facilitative Mediation Program Training - Completed a minimum 16-hour program before January 1, 2003.
Attach copy of certificate and copy of training agenda. Specify the name of the trainer and dates of attendance.

b. Circuit Court Mediation - Completed a minimum 16-hour mediation training program and supplemental 8-hour program related to the training components of Section 2.1 completed before December 31, 2001. Attach copy of certificate and copy of
training agenda. Specify the name of the trainer and dates of attendance.

c. Observed two general civil mediation proceedings. Specify dates and mediator names and attach verification. Do not provide party names.

d. Conducted one general civil mediation to conclusion. Specify date and name of mediator serving as supervisor and attach verification. Do
not provide party names.

e. If not an attorney, applicant must have mediated at least 40 hours or 18 cases in the 2 years before applying. Detail below. Complete
on separate page if needed. Do not provide party names.

f. If the training was completed more than 2 years before applying, applicant must have completed 8 hours of advanced mediation training in the 2 years before applying. Specify type of training, dates, and trainers, and attach copy of certificate.

12. Renewing Application If the mediation training was completed more than 2 years before applying, the applicant must have completed 8 hours of advanced mediation training in the 2 years before applying. Specify type of training, dates, and trainers, and attach copy of certificate.

CERTIFICATION I certify that I: (a) meet the requirements for service under the court's mediator selection plan; (b) will not discriminate against parties or attorneys on the basis of race, ethnic origin, gender, or other protected personal characteristic; and (c) will comply with the court's ADR plan, orders of the court regarding cases submitted to mediation, and the standards of conduct adopted by the State Court Administrator. My hourly fee is $ .

Date

Signature

MC 281a (3/08)

CIVIL MEDIATOR APPLICATION, Page 3 of 4

MCR 2.411(E)

Civil Mediator Application - gender and race information to be maintained separately from pages 1 through 3 of application

Full name (first, middle initial, last) (print or type)

Bar no. (if applicable)

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Part B: Gender and Race Information
Providing the following information is optional. It is requested in accordance with MCR 2.404(E)(1)(c) and will be maintained separately from your application. Check the boxes that apply to you. Gender: Female Race/Ethnicity: American Indian or Alaskan Native Asian or Pacific Islander Black/African American (non-Hispanic) Hispanic White/Caucasian (non-Hispanic) Other (specify): Male

Part C: Observer Information and Pro Bono Services
Providing the following information is optional and will be maintained separately from your application. 1. Once you have been qualified by the court to serve as a mediator: a. Are you willing to be observed by a prospective mediator? b. Are you willing to observe a prospective mediator in mediation pro bono? 2. Are you willing to accept appointment from the court to serve as a pro bono mediator once a year? Yes Yes No No

Yes

No

MC 281a (3/08)

CIVIL MEDIATOR APPLICATION, Page 4 of 4

MCR 2.411(E)