UNITED STATES DISTRICT COURT CENTRAL DISTRICT OF CALIFORNIAMEDIATION PANEL APPLICATION FORMPursuant to Central District of California General Order 11-10, I am applying for appointment to the Mediation Panel. As a condition of service on the Mediation Panel, I agree not to make reference to being a member of the Mediation Panel on a business card, letterhead, or while seeking elective office. The following information is supplied in support of this application:Name: LAST FIRST MIDDLECheck one: New Application Re-Application (check one):No new information is submitted from my previously submitted application(s). If this box is checked, please initial and date where indicated at the end of this section and scan and return by e-mail to ADRCoordinator@cacd.uscourts.gov. INITIAL DATEAdditional/Amended information is submitted on this application; this application is to be attached to my previously submitted application(s) which is in the custody of the ADR Program Office. (Note to applicant: It is not required that you submit additional/amended information in order to be reappointed to the Panel. Such information will only be used to keep your internal file current.) If this box is checked, please date and sign the application on page three and scan and return by email to ADRCoordinator@cacd.uscourts.gov. Business: FIRM NAME SUITE STREET ADDRESS ZIP CODE STATE CITY EXTENSION BUSINESS TELEPHONE BUSINESS E-MAIL ADDRESS BUSINESS FAXState Bar Memberships: DATE OF ADMISSION BAR ID NUMBER STATE DATE OF ADMISSION BAR ID NUMBER STATE DATE OF ADMISSION BAR ID NUMBER STATE DATE OF ADMISSION BAR ID NUMBER STATEDate Admitted to the Bar of this Court: Total number of years of legal practice: Of total caseload, percentage of cases personally handled in federal court within the last five (5) years: % Please list most significant cases personally handled in federal court, excluding pro per representation (list no more than five): APPLICATION MEDIATION PANELADR-19 (07/18)Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Areas of Legal Practice: INDICATE ALL THAT APPLY AND THE LENGTH OF TIME PRACTICED IN EACH AREAPlease provide a brief statement as to how you have demonstrated your expertise in the above-mentioned areas of law and why you consider yourself qualified to be appointed to the Central District's Mediation Panel:Please provide a brief statement as to your trial, litigation, and ADR experience:How did you learn about or who referred you to this Panel? Admiralty ........................................................ Americans with Disabilities Act of 1990 .............................. Antitrust ......................................................... Bankruptcy ...................................................... Business / Commercial Litigation ................................... Civil Rights ...................................................... Class Actions ..................................................... Consumer Credit ................................................. Copyright / Trademark ............................................ Employment Discrimination / Wrongful Termination ................. Environmental ................................................... ERISA ........................................................... Foreclosure ...................................................... Individuals with Disabilities Education Improvement Act (IDEIA) ...... Insurance Coverage / Bad Faith ..................................... Labor ........................................................... Patent ........................................................... Personal Injury ................................................... Product Liability .................................................. Professional Negligence ............................................ Real Estate / Construction .......................................... Securities ........................................................ Tax ............................................................. Transportation ................................................... APPLICATION MEDIATION PANELADR-19 (07/18) Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Please provide the names, addresses and telephone numbers of three (3) references (who the reviewers may contact) who are members of the Bar of the United States District Court for the Central District of California: NAME BUSINESS ADDRESS ZIP CODE STATE CITY(1) OTHER NUMBER (HOME, MOBILE, ETC.) EXTENSION BUSINESS TELEPHONE NAME BUSINESS ADDRESS ZIP CODE STATE CITY(2) OTHER NUMBER (HOME, MOBILE, ETC.) EXTENSION BUSINESS TELEPHONE NAME BUSINESS ADDRESS ZIP CODE STATE CITY(3) OTHER NUMBER (HOME, MOBILE, ETC.) EXTENSION BUSINESS TELEPHONEThere are formal dispute resolution training requirements for all Panel members. To assist the court, please indicate one of the following: Yes, I have attended formal dispute resolution training as follows: No, I have not attended formal dispute resolution training. COURSE PROVIDER HOURS COMPLETED DATE(S) OF TRAINING COURSE NAME COURSE PROVIDER HOURS COMPLETED DATE(S) OF TRAINING COURSE NAME DATE(S) OF TRAINING COURSE PROVIDER HOURS COMPLETED COURSE NAME DATE(S) OF TRAINING COURSE PROVIDER HOURS COMPLETED COURSE NAMENote: Please attach a copy of the completion certificate for each training course listed above.Please attach a resume (1-2 pages) to your application.As a separate endeavor, the district court is looking for volunteer attorneys who are available and willing to represent a pro se litigant, including possibly a prisoner, for the limited purpose of a settlement conference. Please indicate whether you are willing to participate in this project. By signing below, I certify that the information provided on this application is true and correct. I further acknowledge that I have read and understand the Compensation Policy that is set forth in General Order 11-10, 247 3.8. If appointed to the Central District's Mediation Panel, I will adhere to the compensation policy when serving in my official capacity and understand that violation of this policy may serve as grounds for dismissal from the Panel. YES NO DATED SIGNATURE OF APPLICANT APPLICATION MEDIATION PANELADR-19 (07/18)Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com