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 FOR FAMILY DIVISION PRIVATE MEDIATION & COLLABORATIVE PRACTICE PANELS (Do Not Alter this Form in Any Way). Date: Name: Firm Name: Address: County: Phone Number: Email Address: 1. Check each panel for which you are applying: Mediation Collaborative Practice Fax Number: 2. Describe your education, including degrees and the dates received. 3. Briefly describe the ADR training you have received. For each training, give the trainer's name, the dates attended, and the total hours. 4. Describe the subject matter of five disputes for which you have been a mediator or collaborative attorney in the past five years, with the dates. 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 collaborative practice panel, describe 3 collaborative practice cases handled. If you are applying for both panels, describe 5 mediations and 3 collaborative cases, attaching extra pages if necessary.) · · · · · 5. List other court ADR panels of which you are a member, specifying the processes for which you have qualified. FM-1019 REV 01/23/15 APPLICATION FOR FAMILY DIVISION ADR PANEL Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 6. 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. 7. 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): 8. 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. 9. Describe any legal writing or lecturing/teaching you have done. 10. What is your ADR style? 11. List any languages, other than English, in which you can conduct ADR. 12. Describe your fee schedule, including any sliding-scale or pro-bono provisions, as of the date of this application. 13. Give any other information that should be considered in reviewing your application. 14. Please attach a recent resume or CV. FM-1019 REV 01/23/15 APPLICATION FOR FAMILY DIVISION ADR PANEL Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 15. List the names and telephone numbers of three persons familiar with your mediation (for a mediator's application), litigation/evaluation and/or collaborative skills (for a collaborative practitioner's application). If you are applying for both panels, provide 3 mediation references and 3 collaborative practice references, attaching extra pages if necessary. You may not duplicate references. 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 Santa Clara County Superior Court. I agree to waive any and all claims against the Santa Clara County Superior Court 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 case (maximum 10 hours per case) or modest means case a year. I am in good standing with the State Bar of California. I agree to indemnify, defend and hold harmless the Santa Clara County Superior Court, its judges, and employees from any claim, lawsuit, damages or liability of any kind, arising out of any conduct 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: (please print) Signature: MAIL THIS APPLICATION AND ANY ATTACHMENTS TO: ELIZABETH STRICKLAND, ADR ADMINISTRATOR SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CLARA 191 N. FIRST STREET SAN JOSE, CA 95113 OR FAX TO 408-882-2595 FM-1019 REV 01/23/15 APPLICATION FOR FAMILY DIVISION ADR PANEL Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com