ILLINOIS SUPREME COURT MANDATORY COURT-ANNEXED ARBITRATION PROGRAM ELEVENTH JUDICIAL CIRCUIT APPLICATION FOR CERTIFICATION AS AN ARBITRATOR I, certify that I am an attorney and have been duly licensed in the State of Illinois for at least one (1) year and that the following representations are true and correct. SECTION 1 Last Name First Name MI Home Address Phone Number Firm Name Eleventh Circuit Office Address Phone Number FAX Number Date of Birth Social Security Number Illinois Attorney Number (ARDC) Tax Identification Number (FEIN) Year Admitted to the Illinois Bar I am willing to serve as an emergency arbitrator Yes No My litigation experience has been in the following areas (indicate percentage): Personal Injury/Tort Workers Comp Bankruptcy Domestic Relations Administrative Hearings Appellate Chancery Contract Traffic Probate Criminal Tax Real Estate Other (Specify) (PLEASE COMPLETE BOTH PAGES) American LegalNet, Inc. www.USCourtForms.com SECTION 2 (An attorney wishing to be certified as Chairperson should complete this section of the application) I further certify that I have been engaged in trial practice for five years. My activities in the trial practice has consisted of the following:(if necessary use additional page) Please provide the following information regarding litigation experience in the past five years for jury trials or bench trials: Case name Nature of Proceeding Date 1. 2. 3. 4. 5. 6. SECTION 3 (All applicants complete this section) I, certify that all of the above information is true and correct and that if certified as an Arbitrator (Panelist or Chairperson), I do solemnly swear (or affirm) that I will support, obey and defend the Constitution of the United States and the Constitution of the State of Illinois and I will faithfully discharge the duties of my office to the best of my ability. Signature Date FOR OFFICE USE ONLY Training Scheduled: Date Certified: PLEASE RETURN COMPLETED FORM TO: Deborah F. Haas 200 W. Front St., Suite 400B Bloomington, IL 61701 American LegalNet, Inc. www.USCourtForms.com