Free Neutral Application - Missouri

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UNITED STATES DISTRICT COURT EASTERN DISTRICT OF MISSOURI NEUTRAL'S APPLICATION FORM I am applying for certification as a neutral with the United States District Court for the Eastern District of Missouri, in accordance with rules of the Eastern District of Missouri. The following information is supplied in support of this application: 1. Name:
(Last) (First) (M.I.)

Missouri Bar ID Number: 2. 3. Firm's Name: Address:

(City)

(State)

(Zip + Ext.)

4. 5.

Office Phone Number: Date Admitted: a.) The Missouri Bar: b.) Bar of this Court:

6. 7.

Member in good standing with the Missouri Bar?

9 Yes 9 No

Admitted to practice in other jurisdictions? 9 Yes 9 No Please list other licenses:

8.

Seeking certification to serve as a neutral in? (Select One) 9 Mediation 9 Early Neutral Evaluation 9 Both Standard hourly fee for your services; a.) as a neutral in Mediation: b.) as a neutral in ENE: Will you agree to handle a limited number of cases per year pro bono or at a reduced fee? 9 Yes9 No

9.

10.

11.

Please list all areas of substantive law or experience which are or have been a significant part of your legal background or professional practice.

12.

If any response to the following questions is yes, please explain circumstances on a separate sheet and attach. a.) Have you ever been disciplined for violation of any code of professional ethics or responsibility?

b.) c.) d.)

Have you ever been found guilty of a felony? Have you ever been found liable for fraud or any other intentional tort? Have you ever had a professional license revoked or suspended other than for non payment of dues? Have any legal malpractice judgements been entered against you?

e.)

13.

Please list any training or professional education completed by you that qualifies you as a neutral. Include the following information: (Please provide documentation)
Session Sponsor Location Dates Hours

14.

How many of the training hours listed above have been approved by the Missouri Bar for CLE credit?

15.

Are you interested in attending an ADR training seminar sponsored by the United States District Court?

16.

Lists the courts and professional organizations in which you currently hold certifications as a neutral, mediator, arbitrator or other ADR service provider:

17.

In the space below briefly describe your experience, qualifications, special areas of expertise, and any other reasons why you should be selected a neutral.

Signature

Date

NOTE: This form will be made available to parties to assist them in choosing a neutral.

FOR COURT USE ONLY Date Certified by the Court as a neutral: