SUPERIOR COURT OF CALIFORNIA COUNTY OF FRESNO FAMILY LAW MEDIATION PROGRAM FAMILY LAW MEDIATOR PANEL APPLICATION Name: Address: City: State: Phone: Email: Cell Phone Number (optional and for internal use only): Occupation: Employer: Address: City: State: Phone: Email: College Attended: Degree: Graduate or Law School Attended: Degree or Bar #: (Please attach a copy of your CV) Zip Code: FAX: Zip Code: FAX: Date Awarded: Mediation Training (include institutions, programs and dates): Mediation Experience (include number of mediations conducted in the past 3 years): PFL-30 E02-16 OPTIONAL Family Law Mediator Panel Application Form Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com SUPERIOR COURT OF CALIFORNIA COUNTY OF FRESNO FAMILY LAW MEDIATION PROGRAM FAMILY LAW MEDIATOR PANEL APPLICATION Professional Affiliations with Dispute Resolution Organizations; list dates: Years of Practice in Family Law: Foreign Languages in which you are capable of conducting a mediation: Insurance Carrier: Address: City: Phone: Insurance Limits of Liability: (Please attach a copy of your E & O Insurance Declarations Page) State: Zip Code: Current Hourly Rate: Other Relevant Information: Signature below certifies that all of the above information is true and correct and that the applicant agrees to adhere to Court Standards of Professional Conduct. Signature: Return this form to: Date: Mari Henson, ADR Administrator B.F. Sisk Courthouse 1130 'O' Street Fresno, CA 93724-0002 Phone: (559) 457-1908 ~ FAX: (559) 457-1691 mhenson@fresno.courts.ca.gov PFL-30 E02-16 OPTIONAL Family Law Mediator Panel Application Form Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com