MACOMB CIRCUIT COURT ADR MEDIATOR APPLICATION (Not to be used by Case Evaluator Applicants) New application? Part I. General Information Renewal? P# Name Address Home Telephone: Work Telephone: E Mail Address City State and Zip Code ( ( ) ) Fax ( Cell ) Firm or employer's name Work Address City State and Zip If you are only applying for domestic relations mediation, proceed to Part III Part II Civil Mediator Qualifications 1. Qualification through State Court Administrative Office (SCAO) approved civil mediator training: A. I completed a SCAO approved civil mediator training on (attach a certificate of completion of training). I also meet one of the following requirements: 1. I am an: An attorney in good standing? (Provide Bar No.: ); or, I have a or, Graduate degree in conflict resolution? (provide evidence of a degree); . B. 2. 3. 10/6/04 I have 40 hours of mediation, co-mediation, observation, and role-playing 1 American LegalNet, Inc. www.FormsWorkFlow.com experience in the two years prior to this application? Yes. No. Detail your qualifying experience below or complete on a separate page, if needed. Type of Experience Date Hours of mediation 4. I meet the requirement that I observe two general civil mediation proceedings conducted by an approved mediator by the following: Type of case Date Name of approved mediator 5. I meet the requirement that I conduct one general civil mediation to conclusion under the supervision of an approved mediator by the following: Type of case Date Name of approved mediator 6. I have complied with the continuing advanced mediation training requirements of MCR 2.411(F)(4) since completing my initial training. 10/6/04 2 American LegalNet, Inc. www.FormsWorkFlow.com Part III. Domestic Relations Mediator Qualifications 1. I meet at least one of the following criteria: a. I am licensed attorney (Provide Bar No.: ); a licensed or limited licensed psychologist; a licensed professional counselor; or, a licensed marriage and family therapist (provide proof of licensure); or, have a masters degree in counseling, (Provide evidence of masters degree; or, social work, or marriage and family therapy b. c. have a graduate degree in a behavioral science (provide evidence of graduate degree); or, have 5 years experience in family counseling? (provide evidence of 5 years of family counseling (attach separate sheet). . d. 2. I completed a SCAO approved domestic relations mediator training on (attach a certificate of completion of training). Part IV. Anyone seeking to qualify through specialized experience under MCR 2.411(F)(3) or MCR 3.216(G) must consult the Training Standards promulgated by the State Court Administrative Office and present evidence that they meet the criteria provided by the State Court Administrative Office. I certify that I meet the requirements for service under court rules, State Court Administrative Office training criteria and the Macomb County Circuit Court's ADR plan and that I will not discriminate against parties, attorneys, or other mediators on the basis of race, ethnic origin, gender, or other protected personal characteristic. Date Return this application to: Signature Macomb County Circuit Court ADR/Case Evaluation Clerk Court Administration 40 N. Main Mt. Clemens, MI 48043 10/6/04 3 American LegalNet, Inc. www.FormsWorkFlow.com GENDER/RACE/ETHNICITY INFORMATION - OPTIONAL In order to evaluate our efforts to provide bias free mediators and diversity, we ask you to voluntarily identify your gender/race/ethnicity. This information will be maintained separately from the other pages of the application. P Name (First, Middle initial, last. Print or write legibly) Bar No. (if applicable) Please check the appropriate boxes: Gender Male Female Race/Ethnicity American Indian or Alaskan Native Asian or Pacific Islander Black/African American (non-Hispanic) Caucasian White/Caucasian (non-Hispanic) Other Please specify 10/6/04 4 American LegalNet, Inc. www.FormsWorkFlow.com