SUPERIOR COURT OF CALIFORNIA COUNTY OF SACRAMENTO 720 Ninth Street ~ Room 101 Sacramento, CA 95814-1380 www.saccourt.ca.gov (916) 874-5522 MEDIATION PANELIST APPLICATION Please be advised that as a consequence of budget cuts, the Court no longer pays for mediators; in view of their court-appointed status, all mediators are required to provide three hours of pro-bono services per case. Additional hours agreed upon by the litigants are at the expense of the parties. The Court greatly values the panel of volunteers and the benefits the program provides to the litigants, counsel, and the Court. Thank you for your willingness to reside on the panel and submitting your application for review. I. GENERAL INFORMATION Name: Current Occupation: Name of firm: Firm Address: Telephone Number: Facsimile Number: Best time to call: Confidential and Optional: Home telephone number: Home Address: Cell phone number: Length of time employed at firm? E-mail address: II. PROFESSIONAL EXPERIENCE Active Inactive Date admitted to the California Bar: _____________________ Bar Number: _____________________ Are you a certified specialist in any area of law? Yes_____ No_____ If yes, state area of law: Are you licensed in a profession or occupation other than the practice of law? Occupation: State: Licensing Agency: License Number: Yes No Summarize professional experience, particularly during the last five years: APPLICANT'S INITIALS: __________ Mediation Panelist Application CV-E-MED-163 (Revised June 17, 2013) Page 1 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Superior Court of California, County of Sacramento Mediation Employment Place of Employment Position Dates (from ­ to) Language Capabilities Languages, other than English, in which you can conduct a mediation: Degree of Fluency (Comfortable conducting mediation in foreign language): III. SUBJECT MATTER AND PROCESS EXPERIENCE Please indicate no more than four areas in which you have subject matter and process expertise. Personal Injury Employment Business Real Estate/Eminent Domain Professional Malpractice (Indicate legal, medical, etc.) Probate: Estates and/or Conservatorships Construction Defect Public Agency Insurance Environmental Securities and/or Intellectual Property Other Areas of Subject Matter Expertise (Specify) IV. EDUCATION, TRAINING AND EXPERIENCE Please indicate the combination of education, training and experience you possess which you believe qualifies you for inclusion on the mediation panel. Education Dates (from - to) College/University Degree Obtained APPLICANT'S INITIALS: __________ Mediation Panelist Application CV-E-MED-163 (Revised June 17, 2013) Page 2 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Superior Court of California, County of Sacramento Mediation ADR Training Programs Completed (Mediation, arbitration, neutral evaluation, other) Dates (from - to) Type of Training Trainer's Name Number of Hours ADR Experience (Please be cautious not to reveal confidential information) Process Used No. of Cases Case Type No. of Hours Dates (from ­ to) Agency Are you currently an ADR neutral? Yes No (If yes, check as many as apply and list all affiliations on the lines below) Private Practice Firm Organization Volunteer Agency Firm name: ADR organization(s): Volunteer agency(ies): Court approved ADR list (Indicate which court ADR programs): Other agencies or organizations for which you are an approved neutral: Membership in Professional Organizations Organization Location Court Years as Member References Please list persons with whom you have worked as a neutral. We encourage you to be mindful of confidentiality and to seek prior permission to use these names. (Add pages if necessary). If you have not worked as a neutral, list individuals as references who are familiar with your abilities and character. 1. Attorney or Client in: Neutral Evaluation Other (Specify): Mediation Arbitration Name: Position: Organization: Address: Telephone Number: Fax Number: APPLICANT'S INITIALS: __________ Mediation Panelist Application CV-E-MED-163 (Revised June 17, 2013) Page 3 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Superior Court of California, County of Sacramento Mediation 2. Attorney or Client in: Neutral Evaluation Other (specify): Mediation Arbitration Name: Position: Organization: Address: Telephone Number: 3. Attorney or Client in: Fax Number: Mediation Arbitration Name: Position: Organization: Address: Telephone Number: OTHER INFORMATION Neutral Evaluation Other (Specify): Fax Number: Have you ever been convicted of a violation of any federal law, state law, county or municipal law, or Yes No ordinance? If yes, please list on a separate sheet of paper all convictions since your 18th birthday including: offense, date and place of conviction and sentence and the date of release from custody and/or probation/parole as well as details of the offense. Driving under the influence must be reported. Have you ever had any disciplinary actions taken against you by any state, federal, or professional licensing board/agency, court, association or other professional group? Yes No If yes, please describe on a separate sheet of paper the nature of the offense, date of disciplinary action, length of sentence/probation and amount of restitution, if any. Have you ever had a judgment entered against you in connection with your role as an attorney? Yes No If yes, please describe the particulars. APPLICANT'S INITIALS __________ Mediation Panelist Application CV-E-MED-163 (Revised June 17, 2013) Page 4 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Superior Court of California, County of Sacramento Mediation Criminal or disciplinary actions will not automatically bar you from inclusion in the program. Each case is considered individually. Failure to list criminal convictions or professional disciplinary actions taken against you, however, will result in automatic removal from the program. Please provide any other pertinent information reflecting positively or adversely on you which you believe should be disclosed in connection with your possible appointment as a court mediator: TO ALL APPLICANTS: If selected to serve on the Court's Mediation Panel, I agree to the following: 1. Provide three hours of pro-bono mediation. In the event the parties wish to continue beyond three hours, the parties will be responsible for compensating the neutral at his/her agreed-upon rates. The court's mediator panel list will include mediator hourly rate