ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): TELEPHONE NO.: FOR COURT USE ONLY FAX NO.(Optional): E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN DIEGO CENTRAL DIVISION, HALL OF JUSTICE, 330 W. BROADWAY, SAN DIEGO, CA. 92101 EAST COUNTY DIVISION, 250 E. MAIN ST., EL CAJON, CA 92020 NORTH COUNTY DIVISION, 325 S. MELROSE DR., VISTA, CA 92081 SOUTH COUNTY DIVISION, 500 3RD AVE., CHULA VISTA, CA 91910 PLAINTIFF(S) DEFENDANT(S) CASE NUMBER MEDIATOR SELECTION FORM Dept. Date: Assigned Judge: Date of Case Management Conference (CMC) or Stipulation and Order to mediate: (NOTE: If this case was not referred to mediation at the CMC, a Stipulation to Use of Alternative Dispute Resolution Process form (SDSC Form #CIV-359) or other written stipulation to mediate must be filed with the court prior to the assignment of a mediator.) Number of days given by the court to complete the mediation: Primary Mediator: Alternate Mediator: NOTE: If the Primary Mediator is unavailable for assignment, the Alternate Mediator may be automatically assigned to the case.) I, (insert name), certify that the above information is correct, that I have discussed the primary and alternate mediator selection with all parties and/or counsel in the case, and that we have agreed upon the primary and alternate selections as stated above. (NOTE: If you are submitting this form by e-mail, type your full name in the Signature: space provided, which will constitute your electronic signature with the same force and effect as your manual signature.) Contact telephone number during business hours: ( ) - DO NOT MAIL OR FAX THIS FORM. WITHIN FIVE (5) COURT DAYS FOLLOWING THE CASE MANAGEMENT CONFERENCE (CMC), OR AT ANY TIME PRIOR TO THE CMC, YOU MUST EITHER: (1) E-MAIL THE COMPLETED FORM TO: adr@sdcourt.ca.gov (PLEASE BE SURE TO INCLUDE THE CASE NUMBER AND ASSIGNED JUDGE IN THE SUBJECT LINE OF YOUR E-MAIL) OR (2) HAND-DELIVER THE COMPLETED FORM TO THE APPROPRIATE COURT LOCATION: - Central Division - Mediation Office, 330 W. Broadway, Room 241, San Diego, CA 92101 - East County Division - Civil Business Office, 250 E. Main Street, El Cajon, CA 92020 - North County Division - Civil Business Office, 325 S. Melrose Drive, Vista, CA 92081 - South County Division - Civil Business Office, 500 3RD Avenue, Chula Vista, CA 91910 SDSC CIV-005 (Rev. 2/09) MEDIATOR SELECTION FORM American LegalNet, Inc. www.FormsWorkflow.com