Free Mediator Application - California

SUPERIOR COURT OF CALIFORNIA COUNTY OF FRESNO PILOT PROGRAM FOR EARLY MANDATORY MEDIATION MEDIATOR APPLICATION

Name___________________________________________________________ Address_________________________________________________________ City_____________________________________________________________ State________________________________________ Zip_________________ Phone_________________________ Fax______________________________ E-mail___________________________________________________________

Occupation____________________________ How Long__________________ Employer_________________________________________________________ Address__________________________________________________________ City_____________________________________________________________ State_________________________________________Zip_________________ Phone__________________________ Fax______________________________ E-mail___________________________________________________________

College Attended_______________________________ Degree_____________ Graduate or Law School Attended_____________________________________ Degree or Bar #________________________________Date Awarded________

Mediation Training: Include institutions, programs and dates. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________

Mediation Experience: Include number of mediations conducted in past 3 years. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________

MEDIATOR APPLICATION PAGE TWO Professional Affiliations with Dispute Resolution Organizations; give dates. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Areas of Expertise: Business Employment Healthcare Malpractice Real Estate

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Construction Environment Insurance Personal Injury Other

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Foreign Languages in which you are capable of conducting a mediation. ________________________________________________________________ ________________________________________________________________ Insurance Carrier__________________________________________________ Address _________________________________________________________ City _____________________________State _________Zip _______________ Phone ___________________________________________________________ Current Reimbursement Rate ________________________________________ Other Relevant Information __________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Signature below certifies that all of the above information is true and correct and that applicant agrees to adhere to Court Standards of Professional Conduct. Signature ____________________________ Date _______________________

Return this form and your personal narrative to: Mari Henson, ADR Administrator Fresno Civil Courthouse 2317 Tuolumne Street Fresno, CA 93721-1220 (559) 497-4195 Fax (559) 497-4293 [email protected]