ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): FOR COURT USE ONLY TELEPHONE NO.: EMAIL ADDRESS (Optional): ATTORNEY FOR (Name): FAX NO.(Optional): SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN DIEGO CENTRAL DIVISION, CIVIL, 330 W. BROADWAY, ROOM 225, SAN DIEGO, CA. 92101 NORTH COUNTY DIVISION, 325 S. MELROSE DR., VISTA, CA 92081 PLAINTIFF(S) DEFENDANT(S) MEDIATOR SELECTION FORM Dept.: Assigned Judge: Date: CASE NUMBER 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 Alternative Dispute Resolution (ADR) 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. Signature: NOTE: If you are submitting this form by e-mail, type your full name in the 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 CMC, OR AT ANY TIME PRIOR TO THE CMC, YOU MUST EITHER: (1) EMAIL THE COMPLETED FORM TO: adr@sdcourt.ca.gov. INCLUDE THE CASE NUMBER AND ASSIGNED JUDGE IN THE SUBJECT LINE OF YOUR EMAIL. OR (2) HAND-DELIVER THE COMPLETED FORM TO THE APPROPRIATE COURT LOCATION: Central Division - Civil Business Office, 330 W. Broadway, Room 225, San Diego, CA 92101 North County Division - Civil Business Office, 325 S. Melrose Drive, Vista, CA 92081 ) - SDSC CIV-005 (Rev. 1/15) Mandatory Form MEDIATOR SELECTION FORM American LegalNet, Inc. www.FormsWorkFlow.com