Form 3904 SUPERIOR COURT OF CALIFORNIA COUNTY of SOLANO Dispute Resolution Panelist Application Please submit completed application to: ADR Administrator Superior Court of California, County of Solano 580 Texas Street Fairfield, CA 94533 Email:ADR@solano.courts.ca.gov Fax: (707) 425-4996 I. CONTACT INFORMATION Name: Firm/Company/Home: (circle one) Mailing Address: City: State: Zip: E-mail: Phone: Cell: Fax: Emergency Contact: Phone: II. MARK THE PANELS FOR WHICH YOU ARE APPLYING Mediator Neutral Evaluator* Arbitrator** Small Claims Mediator (*Must be licensed attorney with 10 years significant experience or a retired judge.) (**Must be licensed attorney with 5 years experience or a retired judge.) III. PANELS Only complete the panel sections for which you are applying. MEDIATOR A. MEDIATION TRAINING: I have completed a continuous, 40-hour course within the past two (2) years. I have completed a continuous, 40-hour course more than two (2) years ago, and within the past two (2) years I have completed at least seven (7) hours of continuing or advanced mediation training. Other (please specify): (List only 40-hour advanced or specialized mediation courses.) You may add up to one additional page if necessary.) Course Title Instructor (name) Hours Date Rev. 9/22/2014 1 Form 3904 American LegalNet, Inc. www.FormsWorkFlow.com Form 3904 B. MEDIATION EXPERIENCE: List current affiliations with all dispute resolution providers, including the Superior Court of California, County of Solano, other courts, governmental entities and indicate if you are in private mediation practice: (Add up to one additional page if necessary.) Mediate for: Court/Entity/Private # of cases Years C. FEE SCHEDULE: List all fees and expenses that you charge for mediation services. Hourly fee: $ Daily fee: $ Minimum number of hours: Administrative fee: $ Cancellation fee: $ Travel fees: $ Other fees, charges or policies: D. ACKNOWLEDGMENT: If approved as a mediator, I agree to take the Superior Court of California, County of Solano's two (2) hour Mediation Program Orientation course, and meet its continuing education requirement of ten (10) hours every three (3) years, including one hour of ethics. I agree to follow the Superior Court of California, County of Solano's Ethical and Practice Standards for ADR Panel Members. I agree that I have mediated at least six (6) civil cases within the last two years that were at least two hours in length. NEUTRAL EVALUATOR A. NEUTRAL EVALUATION EXPERIENCE: List up to three (3) areas of primary practice focus in which you have had at least ten (10) years of significant legal experience: Please list any specialization for which you are certified: (List trial experience: types of cases tried to verdict or judgment, approximate number of cases, years of practice.) (Add up to one additional page if necessary.) Types of Cases (broad categories) # of Cases Years B. ACKNOWLEDGMENT: If approved as a Neutral Evaluator, I agree to take the Superior Court of California, County of Solano's two (2) hour Helpful Early Neutral Case Evaluation, HENCE, Program Orientation, and meet its continuing education requirement of ten (10) hours every 3 years. I agree to follow the Superior Court of California, County of Solano's Ethical and Practice Standards for ADR Panel Members. Rev. 9/22/2014 2 Form 3904 American LegalNet, Inc. www.FormsWorkFlow.com Form 3904 C. FEE SCHEDULE: List all fees and expenses that you charge for neutral evaluation services. Hourly fee: $ Daily fee: $ Minimum number of hours: Administrative fee: $ Cancellation fee: $ Travel fees: $ Other fees, charges or policies: ARBITRATOR A. ARBITRATION TRAINING: (You may add up to one additional page if necessary.) Course Title Instructor (name) Hours Date B. ARBITRATION EXPERIENCE: (List arbitration experience, including solo arbitration and panels on which you have served, predominant types of cases and approximate number of cases.) Court/Organization Types of Case Arbitrated # of Cases C. FEE SCHEDULE: List all fees and expenses that you charge for arbitration services. Hourly fee: $ Daily fee: $ Minimum number of hours: Administrative fee: $ Cancellation fee: $ Travel fees: $ Other fees, charges or policies: D. ACKNOWLEDGMENT: If approved as a an Arbitrator, I agree to take the Superior Court of California, County of Solano's two (2) hour Arbitration Program Orientation course, and meet its continuing education requirement of 10 hours every three years. I agree to follow the Superior Court of California, County of Solano's Ethical and Practice Standards for ADR Panel Members. SMALL CLAIMS MEDIATOR A. MEDIATION TRAINING: I completed at least 25-hours of a continuous course that meets DRPA standards. (You may add up to one additional page if necessary.) Course Title Instructor (name) Hours Date Rev. 9/22/2014 3 Form 3904 American LegalNet, Inc. www.FormsWorkFlow.com Form 3904 B. MEDIATION EXPERIENCE: (If no mediation experience, please leave blank.) Court # of Cases Mediated Years I have conducted Small Claims Appeals mediations. C. ACKNOWLEDGMENT: If approved as a Small Claims Mediator, I agree to take the Superior Court of California, County of Solano's two (2) hour Small Claims Mediation Program Orientation course, and meet its continuing education requirement of ten (10) hours every three years. I agree to follow the Superior Court of California, County of Solano's Ethical and Practice Standards for ADR Panel Members. IV. AREAS OF EXPERTISE (To be completed by all applicants. Check only areas of actual experience.) Banking Business/Contracts Civil Harassment* Consumer Conservatorship/ Guardianship Construction/Defect Education Eminent Domain Employment/Labor Environment Family Law Custody C Divorce Foreclosure Health Care/Insurance Homeowner Association Intellectual Property Landlord/Tenant Medical Malpractice Partnership Personal Injury Probate/Trust Administration Professional Malpractice Public Entity Real Estate Securities Small Claims Unlawful Detainer* Other * (To mediate Civil Harassment or Unlawful Detainer each has a two-hour update course requirement.) V. BACKGROUND INFORMATION (Indicate all categories that apply to you.) Retired judge Member of the California State Bar: Bar #: Date Admitted: Status: Active Inactive Currently Practicing Represent: Plaintiff: % Defendant: Other: specify: (Contractor, CPA, Therapist, etc#: % VI. EDUCATION (Indicate all levels that apply to you.) High School Diploma GED AA Degree Masters