UNITED STATES DISTRICT COURT MIDDLE DISTRICT OF FLORIDA MEDIATOR'S APPLICATION FORM In accordance with Rule 9.02 of the Rules of the Middle District of Florida, I am applying for certification as a mediator with the United States District Court for the Middle District of Florida. I qualify by the following: Former State Judge and Bar Member of that state Retired Federal Judicial Officer Bar Member of any state or DC for 10 years AND current member of USDC-FLM Bar The following information is supplied in support of this application: Fla. Bar ID No.: Last Name: First/MI: Firm's Name: Mailing Address: City: Zip Code + Ext. Office Phone No: Office FAX No: List names and dates of membership with any state bars or the bar of the District Columbia: Are you a member in good standing of the bar associations listed above? Yes No Date admitted to the Bar of this Court: Date the State Supreme Court's Mediator Certification Program completed: Number of mediation conferences held to date: Check all of areas of legal practice or experience which best describes your legal background. Administrative Law Admiralty Business Litigation Civil Rights Contracts Environmental Law Insurance Intellectual Property Labor Personal Injury Personal Property Products Liability Professional Liability Real Property Social Security Tax Please indicate the Divisions in the Middle District in which you would be willing to serve as a mediator: Ft. Myers Jacksonville E-mail Ocala Orlando Tampa Signature FOR COURT USE ONLY Date certified by the chief judge as a mediator: (Rev. October 2, 2008) American LegalNet, Inc. www.FormsWorkflow.com UNITED STATES DISTRICT COURT MIDDLE DISTRICT OF FLORIDA OFFICE OF THE CLERK United States Courthouse 401 W Central Blvd Orlando, Florida 32801-0210 Anne C. Conway Chief Judge Sheryl Loesch Clerk (407) 835-4200 NOTICE REGARDING THE MEDIATION PROGRAM IN THE MIDDLE DISTRICT OF FLORIDA The Middle District of Florida has adopted a Mediation Program. This Program consists of a supervised settlement conference presided over by a qualified, certified and neutral mediator to promote conciliation, compromise and the ultimate settlement of a civil action. Pursuant to Local Rule 9.02, the chief judge of the District shall certify those persons who are eligible and qualified to serve as mediators under this rule, in such numbers as the chief judge shall deem appropriate. An individual may be certified to serve as a mediator if: (1) He or she is a former state court judge who presided in a court of general jurisdiction and was also a member of the bar in the state in which he presided; or (2) He or she is a retired federal judicial officer; or (3) He or she has been a member of a state bar or the bar of the District of Columbia for at least ten (10) years and is currently admitted to the Bar of this Court. In addition, an applicant for certification must have completed a minimum of 40 hours in the Florida Circuit Court Mediation Training Course certified by the Florida Supreme Court and be found competent by the chief judge to perform mediation duties. If you are interested in becoming a mediator for the Middle District of Florida, and meet the above requirements, please complete the application form on the reverse side, and return to: United States District Court Middle District of Florida United States Courthouse 401 W Central Blvd - Ste 2100 Orlando, Florida 32801-0210 Attention: Joan Calcutt Application deadlines established by the Court are the first business days in January and July. Applications will be considered by the Court on the first deadline after submission. Applicants will be notified in writing regarding the disposition of applications, and each successful applicant will receive a copy of the Court order certifying the applicant as a mediator. Names of certified mediators are included on a roster which is available to the public at the intake section of each division. SHERYL LOESCH, CLERK (Rev.10/2/08) American LegalNet, Inc. www.FormsWorkflow.com