Superior Court of California County of Los Angeles Please return to: ALTERNATIVE DISPUTE RESOLUTION 111 North Hill Street, Room 113 Los Angeles, CA 90012 213-974-5425 CentralADR@LASuperiorCourt.org APPLICATION FOR APPOINTMENT TO ALTERNATIVE DISPUTE RESOLUTION (ADR) PANEL Please type or print the information on this form. Only complete applications will be processed. All items marked with a single asterisk (*) are confidential and not viewable by the public. PERSONAL INFORMATION (Mr./Ms./Mrs./Hon./Dr.) Name: (Last) (First) Current Occupation: (M.I.) Employed by (Firm/Office Name): Mailing Address (can be a post mailbox with physical street address, but not a U.S. post office box): (Street) (Suite) Business Phone: (City) Fax: Home Phone*(optional): (State) E-Mail: Cell Phone*(optional): RANDOM SELECT PANEL REQUEST (Check all panels for which you are applying. Panel (Zip) Private Fee Per Hour: Neutrals with less than 1 year experience may request no more than 2 cases per month.) Panel (specify number) CIVIL (specify number) FAMILY LAW (non-custody) Mediator ____ case referrals per month Mediator ____ case referrals per month Arbitrator ____ case referrals per month Arbitrator ____ case referrals per month Settlement Officer ____ days per year Settlement Officer ____ days per year Neutral Evaluator** ____ case referrals per month Forensic CPA Settlement Officer ____ case referrals per month PROBATE Mediator ____ case referrals per month Settlement Officer ____ days per year **Applicants must also complete the Supplemental Application for Appointment to Neutral Evaluation Panel (LAADR 074). I wish to receive referrals of the following type: On occasion I can accept cases on short notice. Unlimited Jurisdiction Limited Jurisdiction Small Claims I would like to act as a mentor for new panel members. LOCATION OF ADR SESSIONS For the ADR sessions, I prefer to use: Court facilities (applicants outside L.A. County must select at least 1 court facility at which they agree to conduct ADR sessions) Chatsworth Compton Glendale Long Beach Michael Antonovich (Lancaster) Norwalk Pomona South Santa Monica Stanley Mosk (L.A.) Torrance My private facilities Facilities of one of the parties’ counsel ADA Accommodations*: (Neutrals may use LASC facilities for pro bono ADR sessions that require ADA accommodations. If you intend to use your own facilities to conduct the sessions, please indicate which, if any, of the ADA accommodations your facilities offer. This information will not be included in the neutral profiles viewable by the public but will be included in the Random Neutral Search criteria.) Accessible parking Accessible elevators Accessible public phones Accessible tables/counters Accessible entrance Accessible restrooms Assistive listening devices Other (specify): ____________________________ EDUCATION Institution LAADR 006 (Rev. 07/11) LASC Approved 10-03 Degree or Certificate Major APPLICATION FOR APPOINTMENT TO ADR PANEL Start Date End Date Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com LEGAL EXPERIENCE Are you actively engaged in the practice of law at this time? Current primary field of practice: Civil Family Number of years experience: Total active litigation ____ Both Plaintiff and Defense ____ Yes Probate No Criminal Simple case litigation ____ Plaintiff representation ____ Number of years: __________________ Complex case litigation ____ Defense representation ____ EMPLOYMENT HISTORY (last 5 years) Employer Name and Location Position Description Start Date End Date PROFESSIONAL LICENSES Type of License State Date Obtained License Number Status (active/inactive) Please attach a summary of your professional history limited to 600 characters, including punctuation and spaces. Yes No Has your license to practice law in California, or any other state, ever been suspended or revoked?* If yes, please attach a full explanation, including date(s) of suspension or revocation and date(s) of reinstatement. N/A Yes No Has any other professional license been suspended or revoked?* If yes, please attach a full explanation, including date(s) of suspension or revocation and date(s) of reinstatement for each such license. Have any disciplinary actions ever been taken against you by any state, federal, or professional licensing board/agency?* Yes No If yes, please attach a full explanation for each action including nature of offense, date of disciplinary action, length of sentence and/or probation and amount of restitution, if any. Yes No Have you ever been convicted of a felony or misdemeanor?* th If yes, please attach a listing of all convictions since your 18 birthday including offense, date and place of conviction and sentence, and date of release from custody and/or probation/parole. Driving under the influence must be reported. Have any sanctions of $1,000 or more been imposed against you by a court in any single case in the last 5 years, excluding Yes No discovery sanctions?* If yes, please attach a full explanation for each such case. Criminal or disciplinary actions will not automatically bar you from inclusion in the program. Each case is considered individually. However, failure to list criminal convictions or professional disciplinary actions taken against you will result in automatic removal from the program. ADR TRAINING Organization Course Title ADR EXPERIENCE Number of years experience as: Mediator____ Arbitrator____ Are you currently or have you ever been on the Court ADR Panel? Hours Settlement Officer____ Yes No Date Neutral Evaluator____ If yes, indicate dates (from-to): ____________ Transformative Facilitative Evaluative Mediation Work Style: Please attach a description of ADR style and requirements limited to 600 characters, including punctuation and spaces. Yes No Do you require participants to submit a brief? If yes, please attach a description of format and requirements limited to 600 characters, including punctuation and spaces. LAADR 006 (Rev. 07/11) LASC Approved 10-03 APPLICATION FOR APPOINTMENT TO ADR PANEL Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Number of ADR Proceedings Handled (Estimate) CIVIL PANELS: Check box for case types accepted Case Type Med Arb Set Conf Neutral Eval Antitrust/Trade Regulation Auto Tort – Personal Injury/Property Damage/Wrongful Death (PI/PD/WD) Auto Tort – Uninsured Motorist – PI/PD/WD Civil Harassment Construction Defect Contract – Breach of Rental/Lease Contract (not insurance, UD, or wrongful eviction) Contract – Collections Contract – Contract/Warranty Breach – Seller Plaintiff (not insurance, fraud, or negligence) Contract – Contractual Fraud Contract – Insurance Coverage/Subrogation Contract – Negligent Breach of Contract/Warranty (not insurance or fraud) Contract – Other Breach of Contract/Warranty (not insurance, fraud, or negligence) Contract – Tortious Interference Declaratory Relief Only Elder/Dependent Adult Abuse Employment – Labor Commissioner Appeals Employment – Other (not wrongful termination or labor commissioner appeal) Employment – Wrongful Termination Family Injunctive Relief Only (not domestic/harassment) Non– PI/PD/WD Tort – Business/Commercial Tort (not fraud or breach of contract) Non– PI/PD/WD Tort – Civil Rights (e.g., discrimination, false arrest) Non– PI/PD/WD Tort – Defamation (e.g., slander, libel) Non– PI/PD/WD Tort – Fraud (no contract) Non– PI/PD/WD Tort – Intellectual Property Non– PI/PD/WD Tort – Legal Malpractice Other PI/PD/WD Tort – Asbestos Other PI/PD/WD Tort – Intentional (e.g., assault, vandalism, etc.) Other PI/PD/WD Tort – Intentional Infliction of Emotional Distress Other PI/PD/WD Tort – Medical Malpractice Other PI/PD/WD Tort – Premises Liability Other PI/PD/WD Tort – Product Liability (not asbestos, toxic/environmental) Partnership & Corporate Governance Probate Real Property – Eminent Domain/Condemnation Real Property – Mortgage Foreclosure Real Property – Other Real Property – Quiet Title Real Property – Wrongful Eviction Securities Toxic Tort/Environmental Workplace Harassment Writ of Mandate Please attach information about your demonstrated experience in the areas of law or subject matter selected to mediate above. AFFILIATION WITH DISPUTE RESOLUTION PROVIDER ORGANIZATIONS Organization Description of Affiliation Start Date End Date Start Date End Date AFFILIATION WITH DISPUTE RESOLUTION PROFESSIONAL ORGANIZATIONS Organization LAADR 006 (Rev. 07/11) LASC Approved 10-03 Membership Type and Offices Held APPLICATION FOR APPOINTMENT TO ADR PANEL Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com ADR AWARDS Organization Award Date LANGUAGE/BICULTURAL CAPABILITIES Language/Culture Speak Fluent Write Bi-Cultural Capability American Sign Language Amharic Arabic Armenian Bengali Cambodian, Mon-Khmer Chinese - Cantonese Chinese - Mandarin Dutch Farsi Formosan French German Greek Gujarati Hebrew Hindi Hungarian Ibo, Kru, Yoruba (Nigeria) Indonesian Language/Culture Speak Fluent Write Bi-Cultural Capability Italian Japanese Korean Laotian Miao-Yao Polish Portuguese Punjabi Russian Spanish Swedish Syriac Tagalog Tamil Telugu Thai Ukrainian Urdu Vietnamese Other (specify): _______________ Should I be appointed to the Court ADR Panel, I agree to comply with all California statutes, California Rules of Court, and Local Rules, policies, procedures, and requirements applicable to the panel(s) to which I am appointed. I understand that a violation of the statutes, rules, policies, procedures, and requirements may result in suspension and/or removal from the Court ADR Panel. I acknowledge my continuing obligation to notify the ADR department of a felony or misdemeanor conviction, any change in the status of my professional license(s), or any disciplinary actions taken against me. I understand that my failure to do so may result in suspension and/or removal from the Court ADR Panel. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Executed on ________________________ (date) at _________________________________ (city), California. __________________________________________________ SIGNATURE *CONFIDENTIAL – Not viewable by the public. As required by the terms of our funding, please provide the following information for statistical purposes only*: Gender: Male Female Ethnic Background: Asian/Pacific American Hispanic/Latino White Other Black/African American Native American Indian Multiple Ethnicity/Race Date of birth (mm/dd/yy): REVIEWED FOR OFFICE USE ONLY INTERVIEWED AUTHORIZED ENTERED IN ORACLE ENTERED IN CMS NAME DATE LAADR 006 (Rev. 07/11) LASC Approved 10-03 APPLICATION FOR APPOINTMENT TO ADR PANEL Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com