APPLICATION FOR ADMISSION TO ROSTER OF MEDIATORS FOR CIVIL, GENERAL EQUITY AND PROBATE CASES
LAST NAME FIRM/BUSINESS NAME FIRM/BUSINESS ADDRESS (No PO Box) STREET: TELEPHONE NUMBER FAX NUMBER CITY STATE ZIP CODE FIRST NAME MIDDLE NAME
The following information will be used to determine eligibility: (See criteria on back)
HIGHEST DEGREE ATTAINED NAME OF INSTITUTION HAVE YOU EVER BEEN DISCIPLINED IN YOUR PROFESSION? YEAR AREA OF CONCENTRATION PROFESSIONAL LICENSE(S)--Specify type and when obtained.
YEAR OF ADMISSION TO PROFESSIONAL PRACTICE
YES yes, attach explanation.) (If NO
HAVE YOU EVER BEEN CONVICTED OF A CRIME OR ARE CRIMINAL CHARGES PENDING AGAINST YOU?
NUMBER OF YEARS OF EXPERIENCE
BAR ADMISSION YEAR (if applicable) New Jersey Other States Date(s) Hours
(If yes, attach explanation.)
NUMBER OF HOURS OF MEDIATION TRAINING (Attach additional sheet if necessary.) Provider(s) Course Title
NUMBER OF YEARS DOING MEDIATION
NUMBER OF SUCCESSFUL MEDIATIONS
ARE YOU A COURT, STATE, OR LOCAL GOVERNMENT EMPLOYEE OR A LAW ENFORCEMENT OFFICER? YES (if yes, attach NO explanation.)
The following information will be included on the roster if you are accepted:
HOURLY FEE (to be shared by the parties) COUNTIES IN WHICH YOU WILL ACCEPT CASES
AREAS OF EXPERTISE FOR MEDIATION (Please check all that apply.)
DESCRIPTIVE PARAGRAPH (Please provide a maximum of 50 words about your mediation and other relevant professional experience. This information will be transferred directly to the roster if you are accepted.)
997 PROBATE 998 GENERAL EQUITY 005 CIVIL RIGHTS 156 ENVIRONMENTAL COVERAGE LITIGATION 302 TENANCY 303 MT. LAUREL 305 CONSTRUCTION 399 REAL PROPERTY
502 BOOK ACCOUNT 505 OTHER INSURANCE CLAIM (including declaratory judgment actions) 506 PIP COVERAGE 508 COMPLEX COMMERCIAL 509 EMPLOYMENT (other than CEPA or LAD) 510 UM OR UIM CLAIM 511 ACTION ON A NEGOTIABLE INSTRUMENT 512 LEMON LAW
513 COMPLEX CONSTRUCTION 599 CONTRACT/COMMERCIAL TRANSACTION 602 ASSAULT AND BATTERY 603 AUTO NEGLIGENCEPERSONAL INJURY 604 MEDICAL MALPRACTICE 605 PERSONAL INJURY 606 PRODUCT LIABILITY 607 PROFESSIONAL MALPRACTICE
608 TOXIC TORT 609 DEFAMATION 610 AUTO NEGLIGENCEPROPERTY DAMAGE 616 WHISTLEBLOWER 618 LAW AGAINST DISCRIMINATION 699 TORT OTHER 701 ACTIONS IN LIEU OF PREROGATIVE WRIT
I certify that the foregoing statements made by me are true and that I am in good standing in my profession.
Return this form to:
Michelle V. Perone, Esq., Chief, Civil Court Programs, Administrative Office of the Courts PO Box 981 Trenton, NJ 08625 Or Fax to (609) 777-0844.
Must provide documentation that you have handled, as a practitioner, at least 15 lemon law cases in the past 5 years in order to list this case type. Revised 4/29/2009, CN 10523-English page 1 of 2
ROSTER OF MEDIATORS FOR CIVIL, GENERAL EQUITY AND PROBATE CASES Criteria for Admission
Eligibility will be determined by a Subcommittee of the Supreme Court Committee on Complementary Dispute Resolution.
Successful completion of a minimum of 18 hours in an approved mediation course meeting the standards of Rule 1:4012(b)(4) and at least 5 hours being mentored in at least two cases in the Superior Court by an experienced mediator listed on the approved roster of mentors. List of mentors and guidelines for mentoring program are available on the Judiciary Website www.njcourtsonline.com or will be provided by Administrative Office of the Courts subsequent to submission of application.
Education / Mediation Experience (As set forth under Rule 1:40-12(a)(3).
One of the following two combinations of Education and Mediation Experience: 1) Juris Doctor (or equivalent law degree) or Advanced degree in Business, Finance, or Accounting, or Advanced degree in a field of expertise in which the individual will practice mediation (e.g. engineering, architecture, mental health) or State Licensure in the professional field (e.g. CPA, Architect, Engineer) and evidence of successful mediation of at least two cases within the last year. Recent mediation experience is waived if mediation training was completed within the last five years. or 2) Undergraduate degree and evidence of successful mediation of at least ten cases involving subject matter cognizable in the Superior Court within the last five years.
At least five years of professional experience in the field of expertise as set forth under Rule 1:40-12(a)(3).
Annual Continuing Education
Attendance at a minimum of four hours of annual continuing education as set forth under Rule 1:40-12(b)(3).
Counties in Which You Will Accept Cases
Please note that you are expected to provide facilities to the parties at no cost in each county you list and that you cannot charge for travel time or expenses during the first two hours.
Revised 4/29/2009, CN 10523-English
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