Free 39.1 Certification or Recertification form - Washington

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UNITED STATES DISTRICT COURT FOR THE WESTERN DISTRICT OF WASHINGTON FEDERAL BAR ASSOCIATION ADR COMMITTEE Application for Appointment as Mediator/Arbitrator Pursuant to Local Civil Rule 39.1 (As revised pursuant to Order dated October 2, 2000)

Name

WSBA#

I hereby apply for appointment to the Official Register of Qualified Mediators and Arbitrators under Local Civil Rule 39.1. In connection therewith, I hereby certify and represent to the United States District Court for the Western D istrict of Washington that the information provided below is true and correct to the best of my knowledge and belief.
I have been a member of the bar of a Federal District Court for at least seven years or have had at least seven years of judicial experience. I am a member of the bar of the U.S. District Court for the Western District of Washington. I have devoted a substantial portion of my practice to litigation. I have met the following training requirement which the Court has directed by its General Order: During the 36 months immediately preceding the date of this certification, I completed at least 15 hours of mediation training or experience calculated as provided in Section 5 of the U.S. District Court for the Western District of Washington's General Order dated January 17, 1997. I agree to accept appointment to serve as a neutral on a pro bono basis when appropriate.

Signature

Date

Committee Recommendation:

Approve

Disapprove

By: By The Court:

Date: Approve Disapprove

Chief Judge:

Date: