UNITED STATES BANKRUPTCY COURT NORTHERN DISTRICT OF ILLINOIS MEDIATOR'S CERTIFICATE I, the undersigned, hereby apply for designation on the List of Mediators in the United States Bankruptcy Court for the Northern District of Illinois. In making this application, I certify under penalty or perjury that all of the following information is true and correct. A. Nature and level of training and experience in ADR and training programs you have completed: (include names, locations, dates, and CLE credit hours, where applicable, for any Alternative Dispute Resolution ("ADR"). _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Nature and length of experience in bankruptcy (describe your experience as attorney, trustee, accountant, liquidator, reorganization specialist, assignee or in any other bankruptcy-related field in which you have special expertise): _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ B. Professional licenses (identify any professional license that youhold relevant to your service as mediator or neutral, including the issuing body and the date first issued): _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ C. Membership in professional organizations (identify any professional memberships relevant to your service as mediator or neutral to which you currently belong or have belonged in the past and state the time periods during which you were a member): _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ D. (a) Have you ever been the subject of a finding of misconduct in a disciplinary proceeding that resulted in the suspension or revocation of your professional license or a public censure?______________________________________ (b) Have you ever resigned from a professionalorganizationwhile an investigation was pending intoallegations ofmisconduct which would warrant discipline, suspension, disbarment or professional license revocation? ____________________________________________________________ American LegalNet, Inc. www.USCourtForms.com E. F. G. H. (c) Have you ever been removed for cause as a neutral?___________________ (d) Have you ever been convicted of a felony?__________________________ If the answer to any part of question 5 is "Yes," set forth the circumstances surrounding the action in question, including the relevant dates and circumstances: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Other relevant experience, skills, honors, publications, or other information: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Counties in which you are available to conduct mediation conferences: __________________________________________________________________ __________________________________________________________________ General Affirmations: (a) I have read the Local Bankruptcy Rules of the Bankruptcy Court for the Northern District of Illinois governing mediation. (b) I agree to comply fully with the relevant provisions of the Local Bankruptcy Rules, as well as this court's General Orders and any modifications thereto, governing mediation. (c) I will not accept appointment as a mediator in any proceeding or matter unless at the time of accepting the appointment: (1) I qualify as a "Disinterested Person" as defined by 11 U.S.C. § 101, I am free of financial or other interests pursuant to 28 U.S.C. § 455 which would disqualify me if I were a judge, and I am unaware of any other reasons that would disqualify me as a mediator; or (2) I have fully disclosed any potentially disqualifying circumstances and they have been waived by all parties. (d) Upon learning that I am no longer qualified to serve as a mediator pursuant to Rule 9060-5D, I will immediately contact the clerk and any parties for whom I have accepted appointment as mediator. (e) I consent to public disclosure of the information contained in this Application. Signature: ____________________________ Name: _____________________________ (Print or Type) Address: ______________________________ Telephone: ____________________________ Date:__________________________ American LegalNet, Inc. www.USCourtForms.com