Page 1 of 6 T Thhee SSuuppeerriioorr CCoouurrtt COUNTY OF SAN JOAQUIN 222 E. Weber Avenue, Suite 303 Stockton, California 95202 Phone (209)992-5258 www.sjcourts.org CIVIL MEDIATION PROGRAM PANELIST APPLICATION Please note: The information you provide in this application will be used to qualify you for the San Joaquin County Superior Court Civil Mediation Program Panel of Mediators and may also be included in publicity, resource guides, ing the Civil Mediation Program (unless information in a specific section of the application is noted as CONFIDENTIAL). I. GENERAL INFORMATION Name: Last First M.I. Occupation: Firm/Employer: Address: Street City State Zip Code Mailing Address (if different from above): Street City State Zip Code Telephone: ( ) Cell: ( ) Fax: ( ) E-Mail: Date Admitted to the Bar: / / Active Inactive Bar #: State: II. OTHER PROFESSIONAL LICENSURE Occupation: Licensing Agency: State: License #: Occupation: Licensing Agency: State: License #: III. EDUCATION Institution: Location (City/State): Dates of Attendance: Degree Conferred: Institution: Location (City/State): OFFICE USE ONLY American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 6 Dates of Attendance: Degree Conferred: Institution: Location (City/State): Dates of Attendance: Degree Conferred: IV. MEDIATION TRAINING (Please attach additional sheets if necessary) Qualifying Training for panel mediators Refer to attached Minimum Training and Experience Requirements for Court Panel Mediators. Title Training/Program: # of Hours: Date Completed: / / Institution: Location: Title Training/Program: # of Hours: Date Completed: / / Institution: Location: V. MEDIATION EXPERIENCE (Please attach additional sheets if necessary) Qualifying Mediation Experience - Refer to attached Minimum Training and Experience Requirements for Court Panel Mediators. Please be cautious not to reveal confidential information. Type of Case Year # Hours and/or Sessions 1. 2. 3. 4. 5. Mediation Style Please characterize the primary thrust of your mediation style: Facilitative/Nondirective (does not tend to make substantive evaluations but may make process suggestions) Evaluative/Directive (takes a strong role in leading parties to a solution, more of a settlement conference style) Other/Comments: Mediation Rates What are your fees? Per . Do you charge a minimum fee? Yes No If yes, what is the minimum fee? Do you offer sliding scale fees? Yes No American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 6 Please list other ADR Panels (e.g.: federal and/or county court panels, private providers, etc.) on which you have served during the past 5 years: References- Please list only persons with whom you have worked as a mediator. Provide at least two references. We encourage you to be mindful of the confidentiality requirements and to seek prior permission to use these names. This information will be kept CONFIDENTIAL. (Add pages if necessary) Atto rney or Client in a mediation. Name: Position: Organization: Address: Telephone #: ( ) Fax #: ( ) Attorney or Client in a mediation. Name: Position: Organization: Address: Telephone #: ( ) Fax #: ( ) Attorney or Client in a mediation. Name: Position: Organization: Address: Telephone #: ( ) Fax #: ( ) American LegalNet, Inc. www.FormsWorkFlow.com Page 4 of 6 VI. MULTI-LINGUAL ABILITIES Language Speak? Read? Write? Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No VII. SUBJECT MATTER BACKGROUND/EXPERIENCE Area of Experience Legal Experience (# of years) Other Experience (# of years) Experience as a Mediator (# of mediations) Personal Injury Employment Business Real Estate/Eminent Domain Professional Malpractice (indicate legal, medical and/or dental) Probate: Estates and/or Conservatorships Construction Defect Public Agency Insurance American LegalNet, Inc. www.FormsWorkFlow.com Page 5 of 6 Environmental Securities and/or Intellectual Prop erty Other Areas of Subject Matter Expertise (please specify) VIII. INSURANCE Please identify what insurance coverage you have which will be applicable to mediation services you provide (this information will be kept CONFIDENTIAL): Coverage Type: Carrier Name: Limits: (Insurance coverage may become a requirement for panel membership at some future date.) Have you ever been convicted of a felony or misdemeanor? Yes No If yes, on a separate sheet of paper please list 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. 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? Yes No If yes, on a separate sheet of paper, please describe the nature of the offense, date of disciplinary action, length of sentence/probation and amount of restitution, if any. 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. IX. NOTICE TO ALL APPLICANTS If accepted to the Civil Mediation Program as a panel mediator I consent to: Comply with the Rules of Operation including, if necessary, being removed from the panel for failure to comply with the Rules. Attend the panelist orientation and local trainings/meetings. Disclose to both counsel and parties the mediation approaches you most often utilize (e.g., directive vs. facilitative, a combination of styles, etc.). Disclose all fees to counsel and parties. American LegalNet, Inc. www.FormsWorkFlow.com Page 6 of 6 Disclose any conflicts of interest. Be available to conduct mediation sessions in San Joaquin County, if requested by the parties. Agree to handle at least one pro bono or modest means case per calendar year for the program. Fully fill out and return, and encourage counsel and parties to fill out and return, evaluation forms within 10 days following the final mediation session. Report to the Civil Mediation Program staff any criminal convictions which you are involved as well as any disciplinary action taken against you by any state, federal or professional licensing board and/or agency. Be available for observation by Civil Mediation Program staff with the consent of counsel and parities. My signature below certifies that I have made full and accurate disclosure of all information requested in this application form. Signature: Date: Please return application to: Angela Krueg, Civil Mediation Program Manager Mailing Address: P.O. Box 201022, Stockton, CA 95201 Physical Address: 222 E. Weber Avenue, Suite 303, Stockton, CA 95202 Phone (209)992-5258 akrueg@sjcourts.org American LegalNet, Inc. www.FormsWorkFlow.com