(Form 1) Appellate Mediation Program Mediator Application PLEASE PRINT OR TYPE APPLICATION Name: ________________________________________ Street or P.O. Box: ______________________________ County: _______________________________________ Phone: ________________________________________ E-mail: ________________________________________ Firm or Agency: ___________________________ City/Town: _______________________________ Zip Code: ________________________________ Fax No: __________________________________ State Bar No: ______________________________ 1. Have you completed the Alabama appellate mediation training? If so, please attach a copy of your certificate. 2. List the types of mediation training in which you are registered and the dates you received the training. 3. Describe the subject matter of disputes, if any, for which you have been a mediator in the past five years, with the dates. Do not give the names of the parties. State whether you were a sole mediator or a co-mediator. 4. State the name of any organization for which you have provided mediation services during the past five years. 5. Check your areas of substantive expertise: [ [ [ [ [ [ [ [ [ ] ] ] ] ] ] ] ] ] Administrative agencies Attorney fees Business/Contract Construction Corporate Defamation Domestic violence Eminent domain Employment/Labor [ [ [ [ [ [ [ [ [ ] ] ] ] ] ] ] ] ] Environment Family law Health care Housing Insurance Intellectual property Landlord/Tenant Medical malpractice Personal injury [ [ [ [ [ [ [ [ ] ] ] ] ] ] ] ] Probate Products liability Professional negligence Public entity Real estate Securities Workers’ compensation Wrongful death Other (specify): Mediator Application p.1 American LegalNet, Inc. www.USCourtForms.com 6. What is your fee for mediation? 7. How many years have you been in active practice? If none, please explain. 8. What is or was the nature of your practice? 9. Are you certified in any speciality? If so, please list. 10. What percentage of your practice has been representing plaintiffs? ______ 11. Describe your appellate experience. 12. Have you mediated an appellate case? Please state when, where, and the type of case mediated. 13. Is your mediation style facilitative or evaluative? Please explain. 14. Please state any restrictions on your ability to travel throughout the State of Alabama. 15. Would you be willing to conduct a mediation by telephone conference if necessary? _____ Yes _____No 16. List any languages, other than English, in which you can conduct a mediation. defendants? ______ Mediator Application p.2 American LegalNet, Inc. www.USCourtForms.com Please read and sign the following agreement: • • • • I agree to be bound by the Alabama Supreme Court’s Appellate Mediation Rules. I agree to waive any and all claims against the appellate court in connection with my mediation of any court-referred dispute. I agree to mediate pro bono two cases each year. I agree to adhere to the Alabama Code of Ethics for Mediators. Signature: ___________________________________ Date: _______________________________________ Mail this application to: Appellate Mediation Office Alabama Surpeme Court 300 Dexter Avenue Montgomery, Alabama 36104 Mediator Application p.3 American LegalNet, Inc. www.USCourtForms.com