THE VALLEY BAR MEDIATION CENTER(VBMC)

MEDIATOR APPLICATION

(Please complete the following application and return it with your resume or CV.)

SECTION I GENERAL INFORMATION

  1. NAME: ______

Last First Middle

  1. FIRM/AGENCY:______
  1. ADDRESS: ______

Street/P.O. Box

______

City Zip County

  1. BUSINESS PHONE: ______HOME PHONE: ______MOBILE:______
  1. EMAIL: ______
  1. WEBSITE (Optional): ______
  1. EMERGENCY CONTACT: ______

Name Phone

SECTION II E D U C A T I O N / E M P L O Y M E N T / E X P E R I E N C E

  1. EDUCATION (Requirements: Undergraduate bachelor’s degree from a regionally or nationally accrediteduniversity.)

Institution / Degree / Major / Start Date / End Date
  1. EMPLOYMENT HISTORY (Last 5 Years)

Employer Name and Location / Position / Start Date / End Date
  1. PROFESSIONAL LICENSES

Type of License / State / Date Obtained / License Number / Status(active/inactive)
  1. LEGAL EXPERIENCE
  2. Are you actively engaged in the practice of law at this time? (Yes/No) ____
  3. Howmany years of experience ____
  4. Primary area of practice Civil ____ Probate ____ Family ____ Criminal ____

SECTION III A D R T R A I N I N G / A D R E X P E R I E N C E

  1. ADR TRAINING(Requirements:A minimum of 60 hours from providers recognized by the Valley Bar ADR Center; CE or CLE focused on mediation specific topics will be accepted. Training must include at least 30 hours of basic mediator training that meets all DRPA requirements, and at least 10 hours in role play or mediation simulation experience. Non-attorneys must demonstrate that they have had an additional 3 hours in training on litigation and court terminology, which may be from the same training or educational provider that provided all or part of the required 60 hours.)

BASIC TRAINING

Organization / Course Title / Hours / Date obtained/Instructor

ADVANCED TRAINING

Organization / Course Title / Hours / Date obtained / Instructor
  1. EXPERIENCE(Requirements: Panelists must be able to substantiate that they have mediated a minimum of 100 cases. Applicants with a juris doctor degree from a law school or American Bar Association accredited law school or a graduate level degree in conflict resolution from a nationally or regionally accredited university may satisfy this requirement with 50 cases.)
  1. Number of years as a mediator ___
  2. Estimated number of mediations ___
  3. Affiliations with provider or professional organizations (Example: LA Superior Court, ADR Services, EEOC)

Organization / Entity / Number of Years / Start (mm/yyyy) / End (mm/yyyy)
Organization / Entity / Number of Years / Start (mm/yyyy) / End (mm/yyyy)
  1. Areas of Expertise and Experience in Each Area

T Y P E / Estimated # of Mediations
Antitrust/Trade Regulation
Auto Tort – Personal Injury/Property Damage/Wrongful Death (PI/PD/WD)
Auto Tort – Uninsured Motorist – PI/PD/WD
Bankruptcy
Civil Harassment
Construction Defect
Contract – Breach of Rental/Lease Contract (not insurance, UD, or wrongful eviction)
Contract – Collections
Contract – Contract/Warranty Breach – Seller Plaintiff (not insurance, fraud, or negligence)
Contract – Contractual Fraud
Contract – Insurance Coverage/Subrogation
Contract – Negligent Breach of Contract/Warranty (not insurance or fraud)
Contract – Other Breach of Contract/Warranty (not insurance, fraud, or negligence)
Contract – Tortious Interference
Declaratory Relief Only
Elder/Dependent Adult Abuse
Employment
Employment – Not Wrongful termination/Harassment
Employment – Wrongful Termination
Family - Custody
Injunctive Relief Only (not domestic/harassment)
Non– PI/PD/WD Tort – Business/Commercial Tort (not fraud or breach of contract)
Non– PI/PD/WD Tort – Civil Rights (e.g., discrimination, false arrest)
Non– PI/PD/WD Tort – Defamation (e.g., slander, libel)
Non– PI/PD/WD Tort – Fraud (no contract)
Non– PI/PD/WD Tort – Intellectual Property
Non– PI/PD/WD Tort – Legal Malpractice
Other PI/PD/WD Tort – Asbestos
Other PI/PD/WD Tort – Intentional (e.g., assault, vandalism, etc.)
Other PI/PD/WD Tort – Intentional Infliction of Emotional Distress
Other PI/PD/WD Tort – Medical Malpractice
Other PI/PD/WD Tort – Premises Liability
Other PI/PD/WD Tort – Product Liability (not asbestos, toxic/environmental)
Partnership & Corporate Governance
Probate – Trust/Wills
Probate – Conservatorship
Real Property
Real Property – Mortgage Foreclosure
Real Property – Eminent Domain/Condemnation/Zoning
Real Property – Quiet Title
Real Property – Unlawful Detainer
Securities
Toxic Tort/Environmental
Workplace Harassment
Writ of Mandate
Other
  1. Awards

Organization / Award (Description) / Date
  1. List any languages other than English in which you can conduct mediation

______

SECTION IV R E F E R E N C E S

List 3 persons who are familiar with your mediation skills

Name / Organization / Phone number / Email Address

SECTION V E T H I C A L C O N S I D E R A T I O N S

  1. I hereby certify that
  1. No disciplinary action has ever been taken against me by any state, federal, or professional licensing board/agency.
  2. I have not been convicted of a felony or misdemeanor at any time in the past.
  3. If applicable, I am an active member in good standing with the State Bar of California. If not, please explain.

______

______

Name Date Signature

  1. I hereby certify that I have read, and will abide by, the Ethical Standards used in Court mediation programs as stated in the California Rules of Court, Chapter 3, Articles 1 and Article 2.

______

Name Date Signature

iii. I understand that if accepted to the panel that I may be required to provide volunteer services to educate the public about mediation as an alternative to litigation and when appropriate I may offer mediation to those who qualify without charge.

Iv. I hereby certify that the foregoing is true and correct to the best of my knowledge.

______

Name Date Signature

Please provide a recent photo and short bioof your mediation services of not more than 200 words that can be posted on the website of VBMC.

Page 1 of 5