APPLICATION TO SERVE AS A VOLUNTEER MEDIATOR IN THE MEDIATION PROGRAM OF THE DISTRICT OF COLUMBIA Name Daytime Phone Number Business Address Jurisdiction and Date of Bar Admissions Date of Admission to the Bar of the U.S. District Court for the District of Columbia Member in Good Standing? Yes No Area of Legal Expertise American LegalNet, Inc. www.FormsWorkFlow.com Previous Mediation Experience Previous Negotiation Experience Previous Mediation Training (if any), including names of Trainers and Dates of Training Other Relevant Skills and Experience Why are you interested in becoming a District Court Mediator American LegalNet, Inc. www.FormsWorkFlow.com Please attach a copy of your resume, bio or curriculum vitae here: List Of Attachments Number Of Attachments I agree, if selected as a District Court Mediator, to attend a mediation training provided by the court, and to mediate a minimum of 2 cases a year if called upon to do so. Yes No Signature American LegalNet, Inc. www.FormsWorkFlow.com