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