SUPERIOR COURT OF CALIFORNIA COUNTY OF SANTA CLARA Elizabeth Strickland, ADR Administrator 191 North First Street San Jose, California 95113 Fax: 408-882-2595 APPLICATION TO CIVIL DIVISION MEDIATION & NEUTRAL EVALUATION PANELS (Please attach additional pages, if necessary) Date of Application: Name: Street Address: County: Phone Number: Fax Number: Email Address: Please check each panel you are applying for: 1. Mediation Neutral Evaluation Describe your education, including degrees and the dates received. 2. Briefly describe the ADR training you have received. For each training, give the trainer's name, the dates attended, and the total hours. 3. Describe the subject matter of five disputes for which you have been an ADR provider in the past five years, with the dates. Identify the process and state whether you were a sole- or co-provider. (If you are applying for the mediation panel, describe 5 mediation cases handled. If you are applying for the neutral evaluation panel, describe 5 neutral evaluation cases handled. If you are applying for both panels, describe 5 cases under each process, attaching extra pages if necessary.) x x x x x 4. List other court ADR panels of which you are a member, specifying the processes for which you have qualified. CV-5000 REV 3/01/10 APPLICATION FOR MEDIATORS AND NEUTRAL EVALUATION PANELS Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 5. State the name of any organization for which you have provided ADR services during the past five years, giving the dates and the services you provided. 6. Check your areas of substantive expertise: Banking Civil Rights Defamation Elder Issues/Abuse Housing Insurance Labor � Employment Medical Malpractice Partnership Disputes Probate � Wills Securities Other (specify): Business (Commercial � Contract) Construction Disabilities Environment Health Care Intellectual Property Landlord/Tenant Neighborhood Personal Injury Professional Negligence (Non-Medical) Real Estate Tax 7. If you are an attorney, State Bar No.: a). b). c). d). How many years have you been in active practice? If none, please explain. What is or was the nature of your practice? Are you certified in any specialty? If so, please list. What percentage of your practice has been representing plaintiffs defendants ? How many of the following have you completed in the past five years? Jury Trials Court Trials Judicial Arbitrations e.) 8. Describe any legal writing or lecturing/teaching you have done. 9. Is your ADR style facilitative or evaluative/directive? 10. List any languages, other than English, in which you can conduct ADR. 11. Describe your fee schedule, including any sliding-scale or pro-bono provisions, as of the date of this application. 12. Give any other information that should be considered in reviewing your application. CV-5000 REV 3/01/10 APPLICATION FOR MEDIATORS AND NEUTRAL EVALUATION PANELS Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 13. List the names and telephone numbers of three persons familiar with your mediation skills (for a mediator's application) or litigation/evaluation skills (for an evaluator's application). You may attach a letter of recommendation instead of a name. Name Phone Name Phone Name Phone Please read and sign the following agreement: 1. 2. I agree to be bound by the ADR rules of the Superior Court, County of Santa Clara. I agree to waive any and all claims against the Superior Court, Santa Clara County, in connection with my ADR services for a court-referred dispute. I agree to submit any fee dispute arising out of my ADR services for a court-referred dispute to arbitration either under Business and Professions Code section 6200 et seq. or by stipulation or court order. I agree to adhere to the ethical standards for alternative dispute resolution providers as adopted by the court. I agree to accept at least one pro bono or modest means case a year. (Attorney's Only) I am in good standing with the State Bar of California. I agree to indemnify, defend and hold harmless the Superior Court of California, County of Santa Clara, its judges, and employees from any claim, lawsuit, damages or liability of any kind, arising out of any conducting of mine in the rendering of services to any person or persons in connection with my inclusion on the ADR providers' list maintained by the Superior Court. I do do not agree to have my background information posted on the Court's ADR website. 3. 4. 5. 6. 7. 8. Date: Name (print): Signature: MAIL THIS APPLICATION AND ANY ATTACHMENTS TO: ELIZABETH STRICKLAND, ADR ADMINISTRATOR SANTA CLARA COUNTY SUPERIOR COURT 191 N. FIRST STREET SAN JOSE, CA 95113 OR FAX TO 408-882-2595 CV-5000 REV 3/01/10 APPLICATION FOR MEDIATORS AND NEUTRAL EVALUATION PANELS Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com