IDAHO SUPREME COURT APPLICATION FOR REGISTRATION AS A CIVIL CASE MEDIATOR (I....) (Other than Child Custody and Visitation Disputes) GENERAL INFORMATION 1.Mediator Registration: Qualifications of Court Appointed Mediators To be placed on the Supreme Court's list of civil case mediators, the mediator must be a member of theIdaho State Bar who has been admitted to the practice of law for not less than five (5) years. In addition,the mediator must have attended a minimum of forty (40) contact hours of mediation training that meetsthe standards set forth in Rule , Idaho . 2.Supporting Documentation An applicant must submit the following to be placed on a list of mediators maintained by the SupremeCourt: A. The attached application; B. An affidavit of compliance executed by the applicant attesting that the applicant has fulfilled the requirements for registration; C. A copy of the applicant's current Idaho State Bar license; and D. A certificate of completion or other document showing that the applicant's mediation training has been approved by an accredited college or university, the Idaho State Bar, the Idaho Mediation Association, or the Society of Professionals in Dispute Resolution. 3.To Remain on the Supreme Court ListIn order for a mediator to remain on the Supreme Court's list of civil case mediators, the mediator must submit proof thatthey have completed a minimum of five (5) hours of additional training or education during the preceding three (3)calendar years on one of the following topics: mediation, conflict management, negotiation, interpersonalcommunication, conciliation, dispute resolution or facilitation. This training shall be acquired by completing a programapproved by an accredited college or university or by one of the following organizations: Idaho State Bar, or itsequivalent from another state; Idaho Mediation Association, or its equivalent from another state; or Society ofProfessionals in Dispute Resolutions; American College of Civil Trial Mediators; Northwest Institute for DisputeResolution; Institute for Conflict Management; the National Academy of Distinguished Neutrals or any mediationtraining provided by the federal courts. Any program that does not meet this criteria may be submitted for approval eitherprior to or after completion. 4.Applications should be mailed to the Idaho Supreme Court; c/o Administrative Director of the Courts; P.O.Box 83720; Boise, Idaho 83720-0101; telephone # (208) 334-2246. American LegalNet, Inc. www.FormsWorkFlow.com IDAHO SUPREME COURT 451 WEST STATE STREET P.O. BOX 83720 BOISE, IDAHO 83720-0101 (208) 334-2246 APPLICATION FOR REGISTRATION AS A CIVIL CASE MEDIATOR (I.... ) (Other than Child Custody and Visitation Disputes) I herewith apply for registration on the list of court appointed civil case mediators maintained by the Idaho Supreme Court pursuant to Rule I.... In support of this application, I state the following: 225I am a member in good standing of the Idaho State Bar. 225I have been admitted to the practice of law for not less than five (5) years. NAME Organization Mailing Address Suite City County State ZIP Telephone ( ) Extension FAX ( ) E-Mail Address The information you furnish above will be used in all correspondence with you and in the directory of mediators. American LegalNet, Inc. www.FormsWorkFlow.com 225 I have attended a minimum of forty (40) contact hours of mediation training that complies with the standardsset forth in Rule , Idaho . A description of this training is set forthin the attached Addendum Sheet of Mediator Training. 225I submit the following information for inclusion on the Supreme Court's roster of civil case mediators (otherthan child custody and visitation disputes). (Please print or type this information in the space providedbelow using the attached legend of abbreviations where appropriate.) (1) Professional Affiliations: (bar memberships, mediation associations) (2) Education: (3) Legal training and experience: (litigation experience, areas of practice, expertise) (4) Mediation training and experience: (5) Fees and expenses: (6) In addition to the county of my mailing address, I am willing to conduct mediations in the following counties: Signature Date Please return the completed application with supporting documentation to: Idaho Supreme Court Administrative Director of the Courts 451 West State Street P.O. Box 83720 Boise, Idaho 83720-0101 American LegalNet, Inc. www.FormsWorkFlow.com IDAHO SUPREME COURT 451 WEST STATE STREET P. O. BOX 83720 BOISE, IDAHO 83720-0101 (208) 334-2246 APPLICATION FOR REGISTRATION AS A CIVIL CASE MEDIATOR (Other than Child Custody and Visitation Disputes) ADDENDUM SHEET OF MEDIATOR TRAINING (You must use this sheet to list your mediation training sessions.) NAME MEDIATOR TRAINING: Name of Entity Listed Description of Course Contact Below which Sponsored or or Training Hours Dates Approved Training (Attach additional pages if needed.) NOTE: Courses and training sponsored by an accredited college or university do not require further approval. Mediation training sessions conducted by other providers must be approved by the Idaho State Bar, the Idaho Mediation Association, or the Society of Professionals in Dispute Resolution as provided by Rule 16(k) of the Idaho Rules of Civil Procedure. Signature Date American LegalNet, Inc. www.FormsWorkFlow.com IDAHO SUPREME COURT CERTIFICATE OF COMPLETION OF ADDITIONAL CIVIL CASE MEDIATOR EDUCATION Reporting period: through To the Supreme Court of the State of Idaho: I, , hereby certify under penalty of perjury that I have completed five (5) hours of additional mediator education in required topics, as outlined below, which education has consisted of courses, seminars, or training sessions which have been sponsored or approved by an accredited college or university, the Idaho State Bar, the Idaho Mediation Association, or the Society of Professionals in Dispute Resolution, as required by Rule of the Idaho C, Idaho Supreme Court Rules. (Please attach a certificate of completion or other document showing that the mediation education has been approved by one of the above organizations.) (Attach a separate sheet of paper as an addendum to this certificate if additional space is needed.) TOTAL Dated thisday of , 2 . Signature Subscribed and sworn to before me, a Notary Public, this day of , 2 Notary Public: Residing at: Commission expiration date: Course Title and Principal Trainer(s) Course Date(s) Name of Entity Listed Above which Sponsored or Approved Training Course Location Actual Training Hours American LegalNet, Inc. www.FormsWorkFlow.com IDAHO SUPREME COURT APPLICATION FOR REGISTRATION AS A CIVIL CASE MEDIATOR (Other than Child Custody and Visitation Disputes) AFFIDAVIT OF COMPLIANCE State of County of ) ) ss. ) To the Idaho Supreme Court: I, , being first duly sworn, depose and say that: I am the applicant who has signed this application for the placement of my name on the list of civil case mediators (other than child custody and visitation disputes) maintained by the Idaho Supreme Court in accordance with Rule of the Idaho C By signing this application, I certify that I have fulfilled the requirements therein for becoming a registered civil case mediator. I fully realize that the determination as to whether I am placed on the Supreme Court's list of civil case mediators depends on the truth and completeness of my answers set forth in this application and the statements attached. To my knowledge, the answers and information which I have supplied in connection with the application are true and complete. I have read and understand the contents of Ru of the Idaho C and Rule 507 of the Idaho Rules of Evidence, as adopted by the Idaho Supreme Court, relating to civil case mediation and mediator privilege, respectively, and I intend to conduct the mediation of civil cases in conformance with those rules. Date: Applicant's Signature Subscribed and sworn to before me this 2 . day of , (SEAL) Notary Public for Residing at My Commission Expires American LegalNet, Inc. www.FormsWorkFlow.com LEGEND OF ABBREVIATIONS AAA = American Arbitration Association ABA = American Bar Association