Free Mediation - Mediator Application Form - Hawaii

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UNITED STATES BANKRUPTCY COURT - DISTRICT OF HAWAII

APPLICATION FOR APPOINTMENT TO BANKRUPTCY MEDIATOR PANEL
Name: _________________________ Office Address: _________________________ _________________________

Phone / Fax: _________________________

A.

ATTORNEY APPLICANTS Bar membership (minimum 5 years): Hawaii State Bar: District of Hawaii: Other State Bars: ____________ ____________ Date of Admission _______________ _______________ _______________ _______________ Bar Number __________ __________ __________ __________

B.

NON-ATTORNEY APPLICANTS 1. List any professional licenses you hold, including effective dates:

2. List any professional organization of which you are an active member, the length of membership and any positions held and/or projects completed:

3. Describe any relevant experience with bankruptcy cases or law:

C.

ALL APPLICANTS 1. List any state mediation, federal mediation or other alternative dispute resolution training completed:

2. Hourly billing rate for mediation services: $ __________. D. CERTIFICATION

I certify that all information provided in this application is true and correct. I have read and agree to comply with the Guidelines for Bankruptcy Alternative Dispute Resolution, and am willing to provide, without compensation, my services for one 4-hour mediation conference per calendar quarter. I consent to disclosure of the information in this application to the staff of the bankruptcy court, the Bankruptcy Mediation Committee, and the parties and their representatives whose matters have been referred to the BDR program. Dated: ____________________ ___________________________________ Applicant

LBF 9019-2app

3/20/01