NINTH JUDICIAL ADMINISTRATIVE DISTRICT OFFICE OF DISPUTE RESOLUTION 501 Candler Street, NE Gainesville, Georgia 30501 Telephone: 770.535.6909 Facsimile: 770.531.4072 www.adr9.com NEUTRAL REGISTRATION APPLICATION PART I: GENERAL INFORMATION The Ninth Judicial Administrative District Office of Dispute Resolution provides a public listing of the name, registration number, registration categories, and specialty areas for all registered neutrals on our website at www.adr9.com. If you want additional contact information to be available to the public, you may choose to include it by checking the publish option below. Whether or not you give permission to post any optional information on the website listing of neutrals, the Ninth Judicial Administrative District Office of Dispute Resolution furnishes names, addresses, telephone numbers, and registration, expertise, and language fluency information to the public upon request. A. CONTACT INFORMATION All fields are required Title: _____ Name:_____________________________________________________________ Suffix: _____ (e.g. Mr., Ms.) (first name middle initial last name) (e.g. Jr., III) Social Security #: ___________________________ Date of Birth: _____________________ Company: __________________________________________ Mailing Address: (if mailing address is not your home) (Street Name and Number) (Suite or floor numer) (City) (State ) (Zip + 4 ) County: Telephone No. 1: _____________________________ Telephone No. 2: _____________________________ Fax No.: ____________________________________ E-mail: ____________________________________ Publish Information? ____ Yes ____ No Ninth Judicial Administrative District Office of Dispute Resolution Neutral Registration Application American LegalNet, Inc. www.FormsWorkflow.com B. NEUTRAL ACTIVITY Please check all the areas for which you are registered and for which we have certificates on file: General Civil Domestic Relations Domestic Violence Arbitration Case Evaluation Please check all the areas in which you have received training or have had practice experience: Victim Offender Juvenile Probate Court Magistrate Court Superior Court Training Other: ____________________________ What would you identify as your primary occupational field? (Please check only one) Neutral Medical Legal Business Educator Social Services Administrative Ministerial / Religious Other: _______________ What is your current status in your primary occupational field? Student Full-time Part-time Retired Unemployed Are you an attorney? ____ Yes If yes, what is your bar number: ___________________________________________ (State, #. Please include information for multiple states.) Are you a licensed therapist? ____ Yes Are you a minister? ____ Yes C. ADDITIONAL INFORMATION What language(s), other than English, do you speak fluently? Please check all your areas of specialization: Commercial Community Criminal Justice (i.e. Victim Offender) Discrimination Education Employment Environmental Government Health Care Intellectual Property International Labor Personal Injury Real Estate Securities Small Claims Workers’ Compensation Other (please specify): _______________ Ninth Judicial Administrative District Office of Dispute Resolution Neutral Registration Application American LegalNet, Inc. www.FormsWorkflow.com D. BACKGROUND INFORMATION 1. Have you been convicted of, pleaded guilty or nolo contendere to a violation of the law? This includes DUI offenses but excludes traffic violations unless they resulted in suspension or revocation of a driver’s license. You must also report any such pending actions. No Yes If yes, you must provide the following detail on a separate sheet of paper: (1) information concerning the background of the offense(s) which led to each conviction or plea; (2) information concerning the length of time which has elapsed since each conviction or plea; (3) your age at the time of each conviction or plea; and, (4) evidence of rehabilitation since each conviction or plea. 2. Have you been disciplined by any professional organization? You must also report any such pending actions. No Yes If yes, you must provide the following detail on a separate sheet of paper: (1) information concerning the background of the incident(s) which led to the professional discipline; (2) information concerning the length of time which has elapsed since the professional discipline; (3) your age at the time of the professional discipline; and, (4) evidence of rehabilitation since the professional discipline.] 3. Have your professional privileges been curtailed at any time? You must also report any such pending actions. No Yes If yes, you must provide the following detail on a separate sheet of paper: (1) information concerning the background of the incident(s) which led to the curtailment of privileges; (2) information concerning the length of time which has elapsed since the curtailment of privileges; (3) your age at the time of the time of curtailment of privileges; and, (4) evidence of rehabilitation since the curtailment of privileges. 4. Have you relinquished a professional privilege or license while under investigation? You must also report any such pending actions. No Yes If yes, you must provide the following detail on a separate sheet of paper: (1) information concerning the background of the incident(s) which led to the relinquishment of privileges; (2) information concerning the length of time which has elapsed since the relinquishment of privileges; (3) your age at the time of the time of the relinquishment of privileges; and, (4) evidence of rehabilitation since the relinquishment of privileges. MASTER DOCUMENTS (CURRENT)\NEUTRAL REGISTRATION AND RENEWAL MATERIALS/ REGISTRATION APPLICATION 2004 09-14-04.LT/.DOC PAGE 3 American LegalNet, Inc. www.FormsWorkflow.com SIGNATURE PAGE I, □ ______________ , certify that: The information supplied on this application is correct and I will notify the Ninth Judicial Administrative District Office of Dispute Resolution of any address changes. □ I have carefully read Appendix C of the Georgia ADR Rules, “Ethical Standards for Neutrals.” I further certify that I understand the ethical standards and agree to conduct myself in accordance with these standards. I further understand that violation of the “Ethical Standards for Neutrals” may result in disciplinary sanctions, including revocation of registration. □ I understand that all information herein is subject to verification. I understand that by completing this application I am giving my permission to Ninth Judicial Administrative District Office of Dispute Resolution to perform a criminal background check with law enforcement authorities. The results of such an investigation will be used only in considering my suitability for registration with the Ninth Judicial Administrative District Office of Dispute Resolution. Signature of Applicant Date Ninth Judicial Administrative District Office of Dispute Resolution Neutral Registration Application American LegalNet, Inc. www.FormsWorkflow.com