The court strongly prefers that you use the online version of this ADR Neutral Application, available at www.adr.cand.uscourts.gov, under ABecoming A Neutral.@ Please use this form only if you are unable to use the online version. UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF CALIFORNIA ADR NEUTRAL APPLICATION Application for (check one or more): “ MEDIATOR “ ENE EVALUATOR “ ARBITRATOR Please complete the entire application, using additional paper if necessary. Name: Firm or Office Name: Office Address: Office Fax: Office Phone: E-mail address: Website: ADR EXPERIENCE Summarize ADR experience, particularly in the last five years: Other courts or organizations for which you serve as an ADR neutral: Number of sessions conducted as an ADR neutral: ENE: Arbitration: Mediation: Other, specify (e.g. judge pro tem, settlement conference):______________________________ ADR TRAINING Course Provider Course Content Date 1 No. of Hours Role-playing by Participants American LegalNet, Inc. www.FormsWorkFlow.com PRACTICE AREAS For each ADR panel to which you are applying, please check all subject areas in which you believe you are qualified to serve. Note that ENE and Arbitration require greater substantive expertise than Mediation because Evaluators prepare evaluations and Arbitrators render awards on the merits of the case. ENE MED ARB Subject Area ENE MED ARB Subject Area Administrative / Regulatory International Law Antitrust Labor Relations Aviation Land Use/Zoning Banking/Financial Services Landlord/Tenant Bankruptcy Legal Malpractice Business Torts Libel/Slander Constitutional Law General Constitutional-First Amendment Medical Malpractice Construction Maritime-Cargo Consumer Oil & Gas Contracts Partnerships Copyright-General Patent-Biotech/Medical Maritime-Personal Injury Copyright-Information Technology Debtor/Creditor Patent-Chemical PatentComputer/Software Disability: Access Patent-Electrical Disability: Education Patent-Mechanical Disability: Employment Personal Injury Education Police Misconduct Elections Prisoner Civil Rights Eminent Domain / Condemnation Product Liability Employment Discrimination Qui Tam Environmental Railroad ERISA Securities Franchise Sexual Harassment Fraud Tax Government-Contracts Government-Public Agency Law Trade Secrets Health Care UCC Housing Discrimination Unfair Competition ICC Utilities Immigration Wrongful Termination Trademark 2 American LegalNet, Inc. www.FormsWorkFlow.com LEGAL AND OTHER PROFESSIONAL EXPERIENCE Summarize legal or other professional experience (including teaching), particularly in the past five years. Attorney Applicants Only Nature of Practice _______ Litigation: Number of years in active litigation Percentage of practice in last 5 years: representing plaintiffs: % representing defendants: ____% _______ Transactional in federal court: in state court: % % _______ Other Bar Admissions Bar Bar No. Northern District of California: Year of Admission n.a. California Bar Others: specify LEGAL AND OTHER PROFESSIONAL EDUCATION Degree School Year Received OTHER RELEVANT INFORMATION Other relevant information (e.g. publications, professional affiliations, awards, additional experience or skills) SERVING AS A NEUTRAL Mediator and ENE Evaluator Applicants only: Number of court cases per year for which you are willing to serve as a neutral (the minimum is 3 cases per program) Mediation cases: ENE cases: ______ 3 American LegalNet, Inc. www.FormsWorkFlow.com Preference for type of cases you would like to be assigned: Locations in which you are available to conduct ADR sessions: “ San Francisco “ Palo Alto “ San Jose “ Monterey “ Oakland “ Walnut Creek “ Marin County “ Santa Rosa “ Other specify: I consent to public disclosure, including on the court=s internet site, of the information above. “ yes “ no (The court will post your profile only if you are an existing neutral or if you are accepted to an ADR panel.) This section will not be made publicly available. References (if possible, include lawyers or parties in ADR sessions you conducted): Name Phone No. Context in which reference knows you Have you ever: (1) been part of any civil, criminal or administrative proceeding charging you with conduct involving dishonesty, unethical conduct or commission of a crime? or (2) been disciplined or cited for a breach of ethics or unprofessional conduct by any court, administrative agency, bar association, or other professional group, excluding sanctions in an amount less than (if yes, please attach a declaration) $1000, imposed against you in a civil proceeding? ____ yes ______ no I certify that all the foregoing information is true and correct. Date: Signature PLEASE RETURN COMPLETED APPLICATION TO: ADR Unit U.S. District Court 450 Golden Gate Ave. San Francisco, CA 94102 (415) 522-2199 FAX: (415) 522-4112 Email: ADR@cand.uscourts.gov REV.8/08 4 American LegalNet, Inc. www.FormsWorkFlow.com