CSD 4001 [09/08/97] UNITED STATES BANKRUPTCY COURT Southern District of California APPLICATION TO JOIN VOLUNTARY MEDIATION PANEL Name: Address: Applicant is an attorney. California State Bar Number: Phone Number: Are you a member of the United States District Court for the Southern District of California? Yes - Date of Admission: No List three bankruptcy matters in which you have either: a. served as attorney of record from commencement to confirmation or discharge; or, b. served as attorney of record for a party in interest in three or more adversary proceedings or contested matters from commencement through completion (i.e., judgment, order or stipulation). Case Title Case Number Dates 1. 2. 3. Applicant is not an attorney. Applicant is a member of the panel of trustees or examiners maintained by the Office of the United States Trustee or a Certified Public Accountant in the State of California. List ten bankruptcy matters in which you have demonstrated service as either: a. a trustee in an asset bankruptcy estate; or b. a bankruptcy examiner or accountant for a trustee or debtor-inpossession from commencement through completition of such case; or c. or other substantially equivalent service. Case Title Case Number Dates 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. I hereby certify that the undersigned meets the qualifications for membership to the Voluntary Mediation Panel and that the foregoing is true and correct. Dated: FORWARD TO: CSD 4001 2001 © American LegalNet, Inc. (Signature) SAN DIEGO COUNTY BAR ASSOCIATION, Attn: Study Section, 1434 Fifth Avenue, San Diego, California 92101