Free APPLICATION FOR APPOINTMENT TO MEDIATION PANEL - Washington

ADR FORM #1 (4/00) UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF WASHINGTON

APPLICATION FOR APPOINTMENT TO BANKRUPTCY MEDIATION PANEL OF THE UNITED STATES BANKRUPTCY COURT FOR THE EASTERN DISTRICT OF WASHINGTON Notes: (1) Each application must be accompanied by a separate biographical statement of no more than three hundred (300) words in length. An application which does not include such a statement will not be considered. If additional space is need to respond to any item on this application, attach a separate page. This application may be used by lawyers, Rule 9 legal interns and non-lawyers. ____________________________________________________________ ____________________________________________________________ (Street) ____________________________________________________________ (City) (State) (Zip Code) ______________________ Office Fax: ________________________

(2) (3) Name:

Office Address:

Office Phone:

I.

ATTORNEY APPLICANTS

Washington State Bar:

Dates of Admission _____________

Bar Number ___________

Eastern District of Washington: _____________ Other States Bars:_____________ (State) _____________ (State) _____________ _____________ ___________ ___________

II 1.

NON-ATTORNEY APPLICANTS List three matters in which you have resolved disputed issues in a mediation or other alternative dispute resolution format: Matter Description a. b. c. Dates Capacity Description

1.

List any professional organization on which you are an active member, the length of your membership and any positions held and/or projects completed. List any professional licences you hold and include dates of admission. List any relevant bankruptcy experience.

2. 3.

II

RULE 9 INTERNS

Persons eligible to practice pursuant to Local rule 9010-1(a)(2) are eligible to participate in the Bankruptcy Mediation Program. List the date of admission to limited practice under Rule 9 of Admission to Practice Rules of Washington Court Rules. Admission Date: ________________

IV 1.

ALL APPLICANTS List any state mediation, federal mediation or other alternate dispute resolution training that you have completed which has been qualified as continuing professional education credit or which has been approved by a court of competent jurisdiction.

2.

List any state mediation, federal mediation or other alternate dispute resolution program(s) in which you have participated and indicate in what capacity you have participated in such program(s), e.g. as mediator, counsel for a party in mediation, etc.

3.

List any relevant experience, skills, or other information which you would like considered in connection with this application.

4.

List any honors.

5.

List any publications

6.

List speaking engagements, panel/seminar participation, teaching experience, etc.

7.

Check the county(ies) in which you are not willing and not available to conduct mediation conferences: ____ Adams _____ ____ Columbia ____ Garfield ____ Lincoln ____ Stevens Asotin _____ _____ Douglas _____ Grant _____ _____ Okanogan _____ Walla Walla Benton _____ _____ Ferry Kittitas _____ _____ Pend Orielle _____ Whitman Chelan _____ Franklin Klickitat _____ Spokane _____ Yakima

V. / /

CERTIFICATION I am applying for appointment as an attorney mediator. I certify that I am a member in good standing of the state and federal bar(s) listed above. I further certify that the foregoing is true and correct. I am applying for appointment as a non-attorney mediator. I certify that I am a member in good standing of my profession. I further certify that the foregoing is true and correct. I am applying for appointment as a Rule 9 legal intern mediator. I certify that I am admitted to limited practice under rule 9 of the Admission to Practice Rules for the State of Washington. I further certify that the foregoing is true and correct.

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I consent to disclosure of the information contained in this Application to court personnel and to the parties and their representatives whose matters have been referred to the Bankruptcy Mediation

Program.

DATED: __________________

SIGNATURE _______________________