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FOR OFFICE USE ONLY: REG NO

DATE REC'D BKRDCK CHECK(S)

REG DATE RE-REG DATE CHECK(S) AMT.


Alabama Center For Dispute Resolution


Application for Registration

on the Alabama State Court Mediator Roster

Application for registration on the Alabama State Court Mediation Roster is made


pursuant to the mediator registration standards and procedures of the Alabama

Supreme Court Commission on Dispute Resolution effective September 18, 1998, revised May 4, 2007.


Please check the type(s) of registration for which you are applying:

______General Mediation ______Domestic Relations Mediation ______Both


PART I: REGISTRATION STANDARDS


[There is an additional good character requirement and verification (part XII) as well as verification of mediations conducted]


I am applying under the standard checked below:


^ GENERAL CIVIL:

1. I have reached the age of majority in Alabama, and I am licensed as an attorney by one of the fifty

states of the United States or the District of Columbia and in good standing, with four years'

legal or judicial experience; and have successfully completed a 20 hour mediation training program

approved by the Center within 2 years preceding application. To be approved, training

programs must include as part of their curricula, at a minimum, mock mediation exercises and

ethics education, and must include one hour of Alabama mediator ethics; or, check here ______


2. I have reached the age of majority in Alabama, and I have either a baccalaureate degree

and at least five years of management or administrative experience in a professional, business,

or government entity OR a high school diploma and 8 years of management or administrative

experience in a professional, business, or governmental entity; and have completed a 20 hour

mediation training program approved by the Center within 2 years preceding application.

To be approved, training programs must include as part of their curricula, at a minimum, mock

mediation exercises and ethics education, and must include one hour of Alabama mediator ethics.

In addition, I have served professionally (post training) as the mediator in at least 10 mediations

within the 2 years immediately preceding submission of an application for registration, and I will

present documentation of the mediations and names, addresses and telephone numbers of persons

who may be contacted regarding the mediations. check here ______

ACDR 2012

^ DIVORCE/DOMESTIC RELATIONS:


1. I have reached the age of majority in Alabama and I am licensed as an attorney by one of the fifty

states of the United States or the District of Columbia and in good standing, with four years'

legal or judicial experience; and have successfully completed a 40 hour mediation course on

domestic relations issues within 2 years preceding application which has been

(a) certified by the Academy of Family Mediators (AFM) or (b) approved by the Center as

functionally equivalent or superior to an AFM 40 hour course. To be approved, training

programs must include as part of their curricula, at a minimum, mock mediation exercises and

ethics education, and must include one hour of Alabama mediator ethics; or, check here _____


2. I have reached the age of majority in Alabama and I have at least a masters degree and at least

five years of professional experience in any of the fields of psychology, social work, or mental

health and am in good standing with any licensing board or agency and able to present a current

license number if applicable; and have successfully completed a 40 hour mediation course on

domestic relations issues within 2 years preceding application which has been (a) certified by

the Academy of Family Mediators (AFM) or (b) approved by the Center as functionally equivalent

or superior to an AFM 40 hour course. To be approved, training programs must include as part of

their curricula, at a minimum, mock mediation exercises and ethics education, and must include one

hour of Alabama mediator ethics; or, check here ______


3. I have reached the age of majority in Alabama and I have either a baccalaureate degree and at

least eight years of management or administrative experience in a professional, business or

governmental entity OR at least a high school diploma and 10 years of management or

administrative experience in a professional, business, or governmental entity; and have

successfully completed a 40 hour mediation course on domestic relations issues within 2 years

preceding application which has been (a) certified by the Academy of Family Mediators (AFM) or

(b)approved by the Center as functionally equivalent or superior to an AFM 40 hour course. To be

approved, training programs must include as part of their curricula, at a minimum, mock

mediation exercises and ethics education, and must include one hour of Alabama mediator ethics.

In addition, I have served professionally (post training) as a mediator in at least 10 domestic

relations mediations, within the 2 years immediately preceding submission of an application for

registration, and I will present documentation of the mediations and names, addresses and

telephone numbers of persons who may be contacted regarding the mediations. check here _____


ACDR For 2012


^ PART II: BACKGROUND INFORMATION


GENERAL:


1. Name: ______________________________________________________________

Last First Middle

______________________________________________________________________

Law Firm or Organization (Current Employment)

______________________________________________________________________

Street or P.O. Box

______________________________________________________________________

City County State Zip Code


  1. Telephone Numbers: Business ____________________Fax _____________________




  1. Website:_______________________


4. E-mail_____________________________________


5. Date of Birth:________________________________


EDUCATION:


1. What is the highest degree that you have attained to date?_________________________


2. Colleges and universities attended:

Name of school City/State Dates Attended Degree(s) Major

From/To Attained

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________


OCCUPATION:


1. What is/was your primary occupation? Please attach a current resume or vitae to this application.

________________________________________________________________________


2. What is your current employment status?


_____Employed full-time in your primary occupation

_____Employed part-time in primary occupation

_____Retired

_____Unemployed


3. Please list all professional licenses, with license numbers, and affiliations which you consider

relevant to your registration.

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________


  1. If you have been with your current employer less than four years, please list prior employer & dates.

__________________________________________________________________________

__________________________________________________________________________


^ OTHER BACKGROUND:


1. Have you, either as an adult or a juvenile, been convicted for any

violation of any law? Exclude traffic violations unless they resulted in the

revocation or suspension of your license.

_______No _______Yes If yes, list and include dates.


_________________________________________________________________________

_________________________________________________________________________


2. Have you ever been denied a license for a business, trade, or profession (e.g., CPA, real estate

broker, attorney, physician), or had such license revoked?

_______No _______Yes If yes, please explain, and include dates.


_____________________________________________________________________________


3. Have you ever been disbarred, suspended, censured, or otherwise reprimanded, disqualified or

disciplined as an attorney, as a member of another profession, or as a holder of public office?

_______No _______Yes If yes, list and include dates.


_________________________________________________________________________

__________________________________________________________________________


^ PART III: TRAINING


A. Record of General Mediation Training

Describe the general mediation training you have received (minimum of a 20 hour mediation

training program, approved by the Center, including mock mediation exercises and ethics

education).


^ Please attach copies of certificates of completion provided by the trainer.


Course/hours Trainer/Organization Location Date

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________


^ B. Record of Divorce Mediation Training

Describe the divorce mediation training you have received (minimum of a 40 hour divorce mediation training program, approved by the Center, including mock mediation exercises and ethics education).

Please attach copies of certificates of completion provided by the trainer.


Course/hours Trainer/Organization Location Date

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________


^ PART IV: MEDIATIONS

Please detail the most recent five cases where you have served as the mediator. Under "type" please state the subject area, i.e. divorce, banking, employment, construction, etc. (Leave blank if you have not conducted any mediations.) If you are applying under the 10 mediation standard, check here __ and list five additional cases on the back of this sheet. We will need the names of contact persons to verify your mediations. Please see Part VII.

Type Date(s) Name of Mediator Place # of Sessions

1. ________________________________________________________________________________

2. ________________________________________________________________________________

3. ________________________________________________________________________________

4. ________________________________________________________________________________

5. ________________________________________________________________________________

^

PART V: PRACTICE AREAS


If you have expertise in specific subjects that you think might be useful to someone looking for a mediator, please list up to 12 below. Refer to website, www.alabamaadr.org for a list of subjects.

__________________________ _____________________________ _________________________

__________________________ _____________________________ _________________________

__________________________ _____________________________ _________________________

__________________________ _____________________________ _________________________

^

PART VI: COUNTIES

SELECT ALL STATE  OR SELECT UP TO 14 COUNTIES, other than your home county, to which you will travel.

______________________________________________________________________________


______________________________________________________________________________

­­­­­­­­­­­­­­­­­­______________________________________________________________________________


^ PART VII: REFERENCES

List names, addresses and phone numbers of persons (parties, attorneys of parties, judges, co-mediators) who may be contacted regarding your service as a mediator.

Name Address Telephone

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

^ NOTE: If you not yet mediated any cases, list names, addresses and phone numbers of persons who may be contacted as general references.

Name Address Telephone

__________________________________________________________________________________

_________________________________________________________________________________

__________________________________________________________________________________


^ PART VIII: LIMITATIONS

Please identify any limits on your mediation practice, such as subject matter or geography.

____________________________________________________________________________


PART IX: YOUR MEDIATION RATE


______________Hourly or other rate __________________________Other fees or charges


^ PART X: ADDITIONAL LANGUAGES IN WHICH YOU MEDIATE

______________________________________________________________________________


PART XI: APPLICATION/REGISTRATION FEES

I have enclosed the following:

Application fee of $30 _________

Registration fee of $150 ________


Please make checks payable to: The Alabama Center for Dispute Resolution


^ PART XII: AUTHORIZATION AND RELEASE FOR GOOD CHARACTER INVESTIGATION, SIGNATURE AND NOTARY PUBLIC SEAL


For the purpose of suitability for registration and continuation on the Alabama State Court Mediator Roster or the Alabama Arbitrator Roster, I __________________________________________, consent to have an investigation made as to my good character. I authorize the Office(s) of Professional Responsibility where I am licensed (for neutrals who hold a professional license), and/or any other person, firm, company, corporation, court, association, or agency to furnish the Alabama Center for Dispute Resolution (Center) and the Alabama Supreme Court Commission on Dispute Resolution (Commission) with information regarding any charges or complaints filed against me, including any complaints erased by law, whether formal or information, pending or closed, or any other pertinent data; and to permit copies to be made of such documents, records or other information for the purpose of discussion regarding Roster registration. The records will not include any information with respect to a juvenile offense. I give permission to the Center and Commission to contact references and otherwise investigate to verify all information provided.


I agree to notify the Center of any conviction of a misdemeanor or felony within 30 days of such conviction and include copy of the order or orders pursuant to which the conviction was entered. I also agree to notify the Center with a change of address within 30 days. In addition, I certify that the information supplied on this application is correct, and that to the best of my knowledge I qualify for the category of registration of which I have applied. I agree to abide by the Alabama Code of Ethics for Mediators, and to provide up to 10 hours of pro bono mediation if requested.


State of ______________________________________ County of______________________


_____________________________________________ ______________________________

Signature of Applicant Date


Sworn to and subscribed before me this _______ day of __________________, 20_____.


_____________________________________________

Signature of Notary Public


State of ______________________________________


My Commission Expires on:______________________


Please return application and attachments to:

alabama Center For Dispute Resolution

Post Office Box 671

Montgomery, Alabama 36101


ACDR For 2012





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