CSD 4000 [09/08/97] UNITED STATES BANKRUPTCY COURT Southern District of California APPLICATION TO JOIN COMPENSATED MEDIATION PANEL Name: Phone Number: Address: Applicant has completed 25 hours of mediation training at the San Diego Mediation Center or at , which is a training center qualified under Title 16 California Dispute Resolution Act, Section 3615-3635 and Sections 465467.7 of the California Business and Professions Code. The training was completed on . During the preceding calendar year, applicant has 1) conducted two (2) bankruptcy mediations or six (6) hours of mediation for another source. Please describe mediation by case name or other identifying information: OR 2) attended a half-day refresher program provided by the San Diego Mediation Center or an equivalent qualified center consistent with the California Dispute Resolution Act. The refresher program was held on . [Optional] Biographical information is set forth on Exhibit A. [If an attorney] Applicant's California State Bar Number is: Applicant understands that a yearly renewal application must be filed with the Chief Judge of the Bankruptcy Court no later than December 15 of the year prior to the calendar year in which compensated mediation will be conducted. I hereby certify that the undersigned meets the qualifications for membership to the Compensated Mediation Panel and that the foregoing is true and correct. Dated: (Signature) FORWARD TO: SAN DIEGO COUNTY BAR ASSOCIATION Attn: Study Section 1434 Fifth Avenue San Diego, California 92101 CSD 4000 2001 © American LegalNet, Inc. CSD 4000 [09/08/97] - EXHIBIT UNITED STATES BANKRUPTCY COURT Southern District of California MEDIATOR BIOGRAPHICAL INFORMATION Name: Phone Number: Address: Fax Number: Education (list institutions, degrees, dates): Mediation training (list name of trainer and number of hours): Types of disputes handled and subject matter specialties (check all applicable categories): General Bankruptcy/Business/Commercial Community/Neighborhood Construction Employment/Labor Relations Environmental Experience - Governmental/Public Agency Family/Dissolution Personal Injury Property/Real Estate Other: How long have you been providing this service? List relevant organizations, panels, or programs in which you are a member (e.g.; Superior Court Arbitration, American Arbitration Association, Center for Public Resources, etc.): CSD 4000 EXHIBIT A 2001 © American LegalNet, Inc.