APPLICATION UNITED STATES BANKRUPTCY COURT DISTRICT OF MARYLAND BANKRUPTCY DISPUTE RESOLUTION PROGRAM PANEL Name: _______________________________________________________________________ Office Address: ________________________________________________________________ _____________________________________________________________________________ City State Zip Office Phone: ______________________ Office Fax: ________________________ Education: ____________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Professional licenses or memberships and accreditations: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Dispute Resolution Training: Yes ______ No ______ (a) U.S. Bankruptcy Court Training _______ (b) Other Training ________________________________________________________ _____________________________________________________________________________ Experience: ___________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Local Bankruptcy Form J-1 Ver. 0 American LegalNet, Inc. www.FormsWorkFlow.com Counties in which you are willing to serve as a Resolution Advocate: _____________________________________________________________________________ _____________________________________________________________________________ If you are also applying to be a Compensated Resolution Advocate, rates charged: _____________________________________________________________________________ _____________________________________________________________________________ Additional Information: _________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ I hereby certify that the information set forth above is true and correct.1 I agree to serve for a minimum of one year and to act as an unpaid Resolution Advocate in matters, not to exceed one matter per calendar quarter. _________________________ Date ____________________________ Signature Local Bankruptcy Form J-1 Page Two It is the responsibility of the applicant to submit an amended application if any information contained on this application changes. 1 Ver. 0 American LegalNet, Inc. www.FormsWorkFlow.com