FORM 25. Mediator Application Form 25 Rev. 03/16 UNITED STATES COURT OF APPEALS FOR THE FEDERAL CIRCUIT Appellate Mediation Program MEDIATOR APPLICATION Mediators and applicants must not be in active practice as defined by the Federal Circuit Appellate Mediation Program Guidelines. Mediators are not paid for their services, but are reimbursed by the court for minor outof-pocket expenses such as photocopying costs, telephone charges, facsimile charges, and transportation to the courthouse. Mediation proceedings may be held in the courthouse if desired. Reimbursement for reasonable travel and lodging expenses of the mediator is assumed by the litigants if the mediator must travel to conduct the mediation. Information from Candidates: Name Mailing Address Telephone Number Fax Number E-mail Address 1. I am, and have been, a member in good standing of the bar of the following states or the District of Columbia (add extra pages if necessary): State State State Date of Admission Date of Admission Date of Admission 2. I am admitted to practice before the bar of the United States Court of Appeals for the Federal Circuit. Yes No Date of Admission If retired, I retired from the practice of law on American LegalNet, Inc. www.FormsWorkFlow.com FORM 25. Mediator Application Form 25 Rev. 02/16 3. I have a working knowledge of the Federal Circuit's practice and procedures based on the following: 4. No, I have not been disciplined by a court bar, a state bar or the District of Columbia, or the bar of an administrative agency, had a professional license revoked, or been convicted of a felony. Yes, I have (explain on an attached sheet). 5. Yes, I am experienced with the mediation process, having at a minimum (1) represented clients in at least 2 mediations or served as a mediator in at least 2 mediations; and (2) obtained at least 24 hours of CLE-accredited or court-approved mediation training. Please indicate any other experience that you believe is relevant: No, I do not have the requisite experience, but believe I am qualified. Please explain: 6. I am willing to attend mediation training on my own before being assigned as a meditator. Yes No I am willing to attend court-sponsored mediation, if available. Yes No 7. Please outline any previous judicial experience. 8. List additional relevant experience including: (1) professional organizations and any leadership positions held; (2) relevant additional degrees or licenses; and (3) speaking or teaching about mediation (attach additional pages if necessary): American LegalNet, Inc. www.FormsWorkFlow.com FORM 25. Mediator Application Form 25 Rev. 03/16 9. I confirm that I am not in active practice as defined by the Appellate Mediation Program Guidelines at the present time. Yes No The following describes why I believe I am not in active practice: 10. I understand that mediators in the Federal Circuit Appellate Mediation Program will not be compensated for their services. I am willing to serve as a mediator on this pro bono basis. Yes No 11. If selected to be a pro bono Federal Circuit mediator, I expect my level of participation to be 12. I have practice experience in the following areas (check the appropriate boxes): Customs or International Trade Patent Litigation Government Contracts Other Personnel Law Patent and Trademark Office Veterans Law 13. Add any additional information that you wish to bring to the attention of the Federal Circuit. Date Please send completed form to: Federal Circuit Bar Association 1620 I Street, NW, Suite 900 Washington, DC 20006 AND Clerk of Court United States Court of Appeals for the Federal Circuit 717 Madison Place, NW Washington, DC 20439 Signature American LegalNet, Inc. www.FormsWorkFlow.com