SANTA CLARA COUNTY SUPERIOR COURT BACKGROUND INFORMATION / FAMILY DIVISION ADR PANEL Instructions: DO NOT ALTER THIS FORM IN ANY WAY. DO NOT ATTACH ADDITIONAL PAGES. Name Firm Name Street or P.O. Box TODAY'S DATE: Check each panel you are applying for: ____ mediation ____ collaborative practice 1. Describe your education, including degrees and the dates received. City Zip Code Phone Fax 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 a mediator in the past five years, with the dates. State whether you were a sole- or co-provider. · · · · · 4. Check your areas of substantive expertise: ( ) Adoption ( ) Domestic Violence ( ) Domestic Partnership ( ) Estate Planning ( ) Family Law (Divorce, Custody, etc.) ( ) Insurance ( ) Parentage ( ) Real Estate ( ) Tax ( ) Other (specify) ______________________________________ 5. What is your State Bar No.: A. How many years have you been in active practice? If none, please explain. B. What is or was the nature of your practice? C. Are you certified in any specialty? If so, please list. 6. What is your ADR style? 7. Describe your fee schedule, including any sliding-scale or pro-bono provisions. 8. Give any other information that should be considered by parties or counsel. ___________________________________________________________________________________________ BACKGROUND INFORMATION FOR FAMILY DIVISION ADR PANEL 12/05 FM-1020 American LegalNet, Inc. www.USCourtForms.com