Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Mediator Registry Application Form. This is a Indiana form and can be use in Bankruptcy Court Federal.
Loading PDF...
Tags: Mediator Registry Application, Indiana Federal, Bankruptcy Court
UNITED STATES BANKRUPTCY COURT
NORTHERN DISTRICT OF INDIANA
MEDIATOR REGISTRY APPLICATION
Instructions: Please complete this application and return it to the Clerk of Court, United
States Bankruptcy Court, 401 South Michigan Street, South Bend, IN, 46601. If you require
additional space to provide complete information, please attach additional sheets as necessary.
1.
Name & Address
Name: ________________________________ Attorney Number: _____________________
Mediator Number (if registered): _________________________________________________
Business Address: ____________________________________________________________
Telephone: _______________ Fax: _______________ E-Mail: _______________________
2.
Education
Degree: _____________________________________________ Year Obtained: __________
College or University: _________________________________________________________
Degree: _____________________________________________ Year Obtained: __________
College or University: _________________________________________________________
Degree: _____________________________________________ Year Obtained: __________
College or University: _________________________________________________________
American LegalNet, Inc.
www.FormsWorkFlow.com
3.
Professional License(s)
Type: _____________ State Issued: ______ Date: ____________ License No.: ____________
Current Status: _______________________________________________________________
Type: _____________ State Issued: ______ Date: ____________ License No.: ____________
Current Status: _______________________________________________________________
Type: _____________ State Issued: ______ Date: ____________ License No.: ____________
Current Status: _______________________________________________________________
4.
Mediator Training & Experience
Are you certified as a mediator by the State of Indiana?
Check One
Yes
No
Are you certified as a mediator by another state, agency, or other
organization?
Yes
No
(If Yes to either question above) Attach certificate(s) of attendance for each
program you wish the court to consider in determining your mediator qualifications.
Have you ever been subject to disciplinary action as a mediator?
(If Yes) Please attach a statement explaining the current status and
outcome of each action.
Yes
No
Mediation Experience
Type of Mediation _____________________Location ____________ Date _________
Type of Mediation _____________________Location ____________ Date _________
Type of Mediation _____________________Location ____________ Date _________
American LegalNet, Inc.
www.FormsWorkFlow.com
5.
Are you an attorney licensed in the State of Indiana?
If you are a licensed attorney, are you currently in good
standing?
Check One
Yes
No
Yes
No
(If No) Please attach a statement explaining your current status.
6.
Have you ever been convicted of a felony?
Check One
Yes
No
(If Yes) Please attach a statement explaining the circumstances
of your conviction.
7.
Have you ever been the subject of any disciplinary action
affecting your professional license(s)? (If Yes) Please attach
Check One
Yes
No
a statement explaining the current status and outcome of each action.
8.
Have you ever resigned from a professional organization or
surrendered a professional license while an investigation was
pending into allegations of misconduct? (If Yes) Please attach a
Check One
Yes
No
statement explaining the circumstances surrounding your resignation.
9.
Do you agree to accept at least two pro bono mediator
appointments annually?
Check One
Yes
No
American LegalNet, Inc.
www.FormsWorkFlow.com
I affirm under the penalties of perjury that the foregoing representations are true.
I understand that I have a continuing duty to supplement this information and will
immediately notify the court of any event that would, in accordance with the local
rules and general orders of this court, be the basis for the refusal of this application.
I have read the court’s Rules/General Order governing the Alternative Dispute
Resolution Program for the United States Bankruptcy Court for the Northern District of
Indiana, and agree to abide by the provisions and procedures set forth therein.
______________________________________
Signature
____________________
Date
The following information will not influence the approval of your application, but will be
provided to the parties to enable them to make an informed decision during the selection of
a mediator.
Travel & Hourly Rates
Are you willing to travel within the district to mediate cases?
Hourly Rate $ ____________
Check One
Yes
No
Hourly Rate during travel $ ___________
I prefer to mediate cases that deal with the following substantive areas of the law:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
American LegalNet, Inc.
www.FormsWorkFlow.com