Free Microsoft Word - CV-E-MED-163 Mediation Panelist Application.DOC - California


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Date: April 30, 2009
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State: California
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http://www.saccourt.ca.gov/forms/docs/cv-163.pdf

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SUPERIOR COURT OF CALIFORNIA County of Sacramento
720 Ninth Street ~ Room 102 Sacramento, CA 95814-1380 (916) 874-5522--Website www.saccourt.ca.gov

MEDIATION PANELIST APPLICATION
I. GENERAL INFORMATION

Name: Current Occupation: Name of firm: Firm Address: Telephone Number: Facsimile Number: Best time to call:
Confidential and Optional: Home telephone number: Home Address: Cell phone number:

Length of time employed at firm? E-mail address:

II.

PROFESSIONAL EXPERIENCE

Date admitted to the California Bar: _____________________ Bar Number: _____________________

Active

Inactive

Are you a certified specialist in any area of law? Yes_____ No_____. If yes, state area of law: Are you licensed in a profession or occupation other than the practice of law? Occupation: State: Licensing Agency: License Number: Yes No

Summarize professional experience, particularly during the last five years.

APPLICANT'S INITIALS: __________ Mediation Panelist Application CV\E-163 (Rev 02.13.09) Page 1 of 6

Superior Court of California, County of Sacramento Mediation

Employment
Place of Employment Position Dates (From To)

Language Capabilities Languages, other than English, in which you can conduct a mediation: Degree of Fluency (Comfortable conducting mediation in foreign language):

III.

SUBJECT MATTER AND PROCESS EXPERIENCE

Please indicate no more than four areas in which you have subject matter and process expertise. Personal Injury Employment Business Real Estate/Eminent Domain Professional Malpractice (Indicate legal, medical, etc.) Probate: Estates and/or Conservatorships Construction Defect Public Agency Insurance Environmental Securities and/or Intellectual Property Other Areas of Subject Matter Expertise (Specify)

IV.

EDUCATION, TRAINING AND EXPERIENCE

Please indicate the combination of education, training and experience you possess which you believe qualifies you for inclusion on the mediation panel. Education
Dates (from to) College/University Degree Obtained

APPLICANT'S INITIALS: __________ Mediation Panelist Application CV\E-163 (Rev 02.13.09) Page 2 of 6

Superior Court of California, County of Sacramento Mediation

ADR Training Programs Completed (mediation, arbitration, neutral evaluation, other)
Dates (from to) Type of Training Trainer's Name Number of Hours

ADR Experience (Please be cautious not to reveal confidential information.)
Process Used No. of Cases Case Type No. of Hours Dates (from to) Agency

Are you currently an ADR neutral? affiliations on the lines below) Private Practice Firm

Yes

No (If yes, check as many as apply and list all Volunteer Agency Court

Organization

Firm name: ADR organization(s): Volunteer agency (ies): Court approved ADR list (indicate which court ADR programs): Other agencies or organizations for which you are an approved neutral: Membership in Professional Organizations
Organization Location Years as Member

References Please list persons with whom you have worked as a neutral. We encourage you to be mindful of confidentiality and to seek prior permission to use these names. (Add pages if necessary). If you have not worked as a neutral, list individuals as references who are familiar with your abilities and character. 1. Attorney or Client in: Neutral Evaluation Other (specify):

Mediation Arbitration Name: Position: Organization: Address: Telephone Number:

Fax Number:
APPLICANT'S INITIALS: __________ Mediation Panelist Application

CV\E-163 (Rev 02.13.09)

Page 3 of 6

Superior Court of California, County of Sacramento Mediation

2.

Attorney or

Client in: Neutral Evaluation Other (specify):

Mediation Arbitration Name: Position: Organization: Address: Telephone Number: 3. Attorney or Client in:

Fax Number:

Mediation Arbitration Name: Position: Organization: Address: Telephone Number: OTHER INFORMATION

Neutral Evaluation

Other (specify):

Fax Number:

Have you ever been convicted of a violation of any federal law, state law, county or municipal law, or ordinance? Yes No If yes, please list on a separate sheet of paper all convictions since your 18th birthday including: offense, date and place of conviction and sentence and the date of release from custody and/or probation/parole as well as details of the offense. Driving under the influence must be reported. Have you ever had any disciplinary actions taken against you by any state, federal, or professional licensing board/agency, court, association or other professional group? Yes No

If yes, please describe on a separate sheet of paper the nature of the offense, date of disciplinary action, length of sentence/probation and amount of restitution, if any.

Have you ever had a judgment entered against you in connection with your role as an attorney? Yes No . If yes, please describe the particulars.

APPLICANT'S INITIALS __________

Mediation Panelist Application CV\E-163 (Rev 02.13.09) Page 4 of 6

Superior Court of California, County of Sacramento Mediation

Criminal or disciplinary actions will not automatically bar you from inclusion in the program. Each case is considered individually. Failure to list criminal convictions or professional disciplinary actions taken against you, however, will result in automatic removal from the program. Please provide any other pertinent information reflecting positively or adversely on you which you believe should be disclosed in connection with your possible appointment as a court mediator:

TO ALL APPLICANTS: If selected to serve on the Court's Mediation Panel, I agree to the following: 1. Receive compensation in the amount of $200 as payment in full from the court to conduct three hours of mediation. In the event the parties wish to continue beyond three hours, the parties will be responsible for compensating the neutral at his/her agreed-upon rates. The court's mediator panel list will include mediator hourly rates. For this purpose, please provide your hourly rate: _________________________. Comply with the General Rules Relating to Mediation of Civil Cases contained in California Rules of Court Sections 10.781 through 3.810 et seq. Disclose all fees to counsel and parties. Disclose any potential conflicts of interest. Be available to conduct mediation sessions in Sacramento County if requested by the parties. Conduct two court mediation sessions in a six month period with the option to mediate additional cases if interested. Complete and return the Statement of Agreement or Non-agreement form to the court within ten days from the date the mediation is held. Complete and return, and encourage mediation participants to complete and return, evaluation forms within 10 days following the final mediation session. Report to the ADR Administrator any criminal convictions in which I am involved in or become involved in as well as any disciplinary action taken against me by any state, federal or professional licensing board and/or agency.
APPLICANT'S INITIALS: __________

2.

3. 4. 5.

6.

7.

8.

9.

Mediation Panelist Application CV\E-163 (Rev 02.13.09) Page 5 of 6

Superior Court of California, County of Sacramento Mediation

10. Be available for observation by ADR staff with the consent of counsel and parties. 11. 12. Attend training sessions sponsored by the court as may be required. Not to exploit my service as a court mediator by including reference to such position in any advertising, or on any letterhead, business card, or telephone listing (listing on a vita is permissible)

CERTIFICATION OF APPLICANT: I hereby certify that all statements made in this entire application, including attachments, are true and complete to the best of my knowledge. I understand that any false, incomplete, or incorrect statement, regardless of when it is discovered, may result in my disqualification or dismissal from a position as court mediator. I understand that service as a court mediator is at the pleasure of the court, and that I may be removed from the court mediator list at any time without notice or cause. I hereby authorize all my employers and schools to release any and all information concerning me, including information of a confidential and privileged nature. I HEREBY RELEASE ANY AND ALL EMPLOYERS AND THE SUPERIOR COURT OF CALIFORNIA, COUNTY OF SACRAMENTO, FROM ANY LIABILITY OR DAMAGE WHICH MAY RESUILT FROM FURNISHING THE INFORMATION REQUESTED. My signature below further certifies that I have made full and accurate disclosure of all information requested in this application form. Signature: Date:

Please return application to: Superior Court of Sacramento County 720 9th Street, Room 101 Sacramento, CA 95814 Attention: ADR Administrator Telephone Number: (916) 874-1571 Facsimile Number: (916) 874-5620

APPLICANT'S INITIALS: __________

Mediation Panelist Application CV\E-163 (Rev 02.13.09) Page 6 of 6