Mediator Application (Third Appellate District) Form. This is a California form and can be use in Third Appellate District Court Of Appeals.
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STATE OF CALIFORNIA COURT OF APPEAL, THIRD APPELLATE DISTRICT APPELLATE MEDIATION PROGRAM—SACRAMENTO MEDIATOR APPLICATION (Please attach your résumé and any additional pages required.) EXCEPT FOR PAGE 4, THE INFORMATION PROVIDED IN THIS APPLICATION IS NOT CONFIDENTIAL AND MAY BE DISCLOSED TO MEMBERS OF THE PUBLIC. ________________________________________________________________________________________________________________ Name:_______________________________________________________________ State Bar No. _______________ Firm Name (or Agency): ___________________________________________________________________________ ___________________________________________________________________________________________________ Office Address (or P.O. Box), City or Town, County and Zip Code Office Phone: ____________________ Fax: _____________________ E-mail: _____________________________ ___________________________________________________________________________________________ 1. List your education, including schools, degrees and the dates received. 2. Describe any mediation training you have received. 1 For each training, give the trainer’s name, the dates attended and the total hours if available. 3. Identify the subject matter of five disputes 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. (a) _____________________________________________________________________________ _____________________________________________________________________________ (b) _____________________________________________________________________________ _____________________________________________________________________________ (c) _____________________________________________________________________________ _____________________________________________________________________________ (d) 1 _____________________________________________________________________________ Previous mediation training is not required. -1- American LegalNet, Inc. www.FormsWorkFlow.com _____________________________________________________________________________ (e) _____________________________________________________________________________ _____________________________________________________________________________ 4. List other court mediation panels of which you are a member. ____________________________________________________________________________________ Identify any other significant mediation experience you have had. 2 5. ____________________________________________________________________________________ ____________________________________________________________________________________ 6. Check your areas of practice: Attorney Fees Health Care Professional Negligence Business Housing Public Entity Contract Insurance Real Estate Construction Intellectual Property Securities Defamation Landlord/Tenant Appellate Eminent Domain Medical Malpractice Other: Employment Partnership Labor Personal Injury Family Law Probate 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 specialty? If so, please list. 10. What percentage of your practice has been representing: Plaintiffs: ____% 11. Defendants: ____% Approximately how many of the following have you completed in the past five years? Jury trials: ___ Court trials: ___ Arbitrations: ___ Appeals: ___ Administrative Proceedings: ___ 12. 2 Describe your appellate experience. No prior mediation experience is required. -2- American LegalNet, Inc. www.FormsWorkFlow.com 13. Is your mediation style facilitative or evaluative/directive? 14. List any languages, other than English, in which you can conduct a mediation. 15. If the parties and you agreed to continue the mediation beyond four hours, what hourly rate would you charge? Would you consider continuing pro bono? If so, please explain. 16. State any other information that should be considered in respect to your application. Please read and sign the following agreement: A. B. In consideration of the free appellate mediation training to be provided by the Court of Appeal (the Court), I agree to accept up to four (4) mediation referrals. With respect to each mediation that I conduct, I agree to provide up to four (4) hours of mediation with the parties free of charge. In the event that the parties agree to have me mediate their dispute beyond four hours, the parties may do so by agreeing to pay me for my services at my ordinary hourly rate stated above. I acknowledge that in no circumstances shall the Court be responsible for paying me any fees, by way of direct payment, guarantee or otherwise. Rather, in the event that I provide services in addition to the four hours of free services, the parties shall be solely responsible for my fees. C. I agree to be bound by the Court’s mediation rules and procedures. D. I agree to waive any and all claims against the Court arising out of my mediation of any Courtreferred dispute. I acknowledge that I am an independent contractor and that I serve as a mediator at the will of the Court. The Court may terminate my services as mediator at any time for any reason. E. I agree to adhere to the Alternative Dispute Resolution Rules for Civil Cases as set forth in the California Rules of Court. Date: ________________________ Name: _____________________________________ (print) ______________________________________ (signature) MAIL OR FAX THIS APPLICATION WITH YOUR RÉSUMÉ AND ANY OTHER ATTACHMENTS TO: Rene Ackerman, Judicial Secretary to the Mediation Program COURT OF APPEAL, THIRD APPELLATE DISTRICT 2890 Gateway Oaks Drive, Suite 210 Sacramento, California 95833 -3- TEL: (916) 274-5895 FAX: (916) 641-6527 EMAIL: email@example.com American LegalNet, Inc. www.FormsWorkFlow.com *********************THIS PAGE IS CONFIDENTIAL AND FOR COURT USE ONLY********************* Name:_______________________________________________________________ State Bar No. _______________ R EFERENCES List the names and telephone numbers of three persons familiar with your mediation (M) or appellate (A) skills, indicating which applies: Name Phone -4- M American LegalNet, Inc. www.FormsWorkFlow.com A