OAKLAND COUNTY CIRCUIT COURT CIVIL MEDIATOR APPLICATION For further information, including information about minimum qualifications promulgated by the State Court Administrative Office, please refer to the SCAO Mediation Training Standards and Procedures and MCR 2.411. Service as a case evaluator under MCR 2.403 does not constitute a qualification for serving as a mediator. Note: Except for Part D, the information provided in this application is available to the public for inspection. Please type or print neatly. 1. Full name (first, middle initial, last) 2. Bar no. (if applicable) P 3. Address where you can be contacted 4. Telephone no. 5. Fax no. 6. E-mail address: Part A: General Information Complete item 7 and either 8, 9, 10, 11 or 12 as appropriate 7. Is this a new application? renewal? If renewing, complete item 12 and attach a copy of your original application. Part B: General Civil Mediator Qualifications (Complete either item 8, item 9, item 10 or item 11 as appropriate) Where indicated you must provide the written evidence requested. 8. Qualification through State Court Administrative Office (SCAO) Approved Training To be eligible to serve as a general civil mediator, you must meet the following minimum qualifications: • You must have completed a training program approved by the State Court Administrator. • You must have one or more of the following: a) a juris doctor degree; b) graduate degree in conflict resolution; or c) 40 hours of mediation experience over two years, including mediation, co-mediation, observation, and role-playing in the context of mediation. • You must have observed two general civil mediation proceedings conducted by an approved mediator, and have conducted one general civil mediation to conclusion under the supervision and observation of an approved mediator. a. SCAO Approved training completed on _______________________________. Please attach a certificate of completed training. Date Trainer: _________________________________________________________________________________________________ b. Juris Doctorate - Attach a copy of diploma if not a licensed attorney Graduate degree in conflict resolution - Attach copy of diploma 40 hours of mediation, co-mediation or role-playing experience in the two years prior to this application. Detail below. Co-mediation can be documented as either experience or observation – do not count the same case twice. Complete on separate page if needed. Case Type Date Length of Time _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ CE 1 (03/06) MCR 2.411(E) 1 American LegalNet, Inc. www.FormsWorkflow.com Part B: General Civil Mediator Qualifications (continued) 8. c. Observed or co-mediated two general civil mediation proceedings. Specify dates and name of qualified * mediator who observed or co-mediated. Co-mediation can be documented as either experience or observation – do not count the same case twice. Do not include party names. Date Name of Qualified Mediator ________________________________________________________________________________________________________ _______________________________________________________________________________________________________ d. Conducted under supervision or co-mediated one general civil mediation to conclusion. Specify date and name of qualified * mediator who observed or co-mediated. Co-mediation can be documented as either experience or observation – do not count the same case twice. Do not include party names. Date Name of Qualified Mediator ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ 9. Qualification by Comparable Training and Experience; Community Dispute Resolution Program (CDRP) Note: To qualify under this section, CDRP training must have been completed prior to February 10, 2001. a. Michigan CDRP training completed on ________________________________. Please attach a certificate of completed training. Date Trainer: _______________________________________________________________________________________________ b. If training was completed more than two years prior to the application, completed 8 hours of advanced mediation training in the 2 years prior to this application. Specify type of training, dates and trainers and attach copy of certificate. ________________________________________________________________________________________________________ c. If not a lawyer or hold a graduate degree in dispute resolution, mediated or co-mediated at least 40 hours or 18 cases in the 2 years prior to the application. Detail below. Co-mediation can be documented as either experience or observation – do not count the same case twice. Complete on separate page if necessary. Do not provide party names. Case Type Date Length of Time ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ d. Observed or co-mediated two general civil mediation proceedings. Specify dates and name of qualified * mediator who observed or co-mediated. Co-mediation can be documented as either experience or observation – do not count the same case twice. Do not include party names. Case Type Date Length of Time _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ *Please see list of qualified mediators at the Oakland County ADR Office 2 American LegalNet, Inc. www.FormsWorkflow.com Part B: General Civil Mediator Qualifications (continued) e. Conducted under supervision or co-mediated one general civil mediation to conclusion. Specify date and name of qualified * mediator who observed or co-mediated. Co-mediation can be documented as either experience or observation – do not count the same case twice. Do not include party names. Date Name of Qualified Mediator ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ f. 10. As a non-lawyer or a non-Michigan licensed lawyer, completed on __________________________________ a 6-hour program addressing basic Michigan laws, rules, and guidelines governing civil actions. Trainer: ___________________________________________________________ Qualification by Comparable Training and Experience; Other Training and Experience Note: To qualify under this section, you must have completed at least a 24-hour training by February 10, 2001 or a 16-hour training and an 8-hour supplemental course with the same trainer approved by the SCAO by September 28, 2001. a. Completed a comprehensive training course of at least 24 hours designed for general civil case mediation. Attached are: 1) certificate of completed training; 2) a copy of the training agenda; 3) the name of the trainer; 4) the date of the training; and 5) the dates of attendance. b. If the training was completed more than 2 years prior to this application, completed at least 8 hours of advanced mediation training in the 2 years prior to this application. Specify type of training, dates, and trainers and attach copy of certificate. _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ c. Observed or co-mediated two general civil mediation proceedings. Specify dates and name of qualified * mediator who observed or co-mediated. Co-mediation can be documented as either experience or observation – do not count the same case twice. Do not include party names. Date Name of Qualified Mediator ________________________________________________________________________________________________________ _______________________________________________________________________________________________________ d. Conducted under supervision or co-mediated one general civil mediation to conclusion. Specify date and name of qualified * mediator who observed or co-mediated. Co-mediation can be documented as either experience or observation – do not count the same case twice. Do not include party names. Date Name of Qualified Mediator ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ 3 American LegalNet, Inc. www.FormsWorkflow.com If not an attorney, mediated or co-mediated at least 40 hours or 18 cases in the two years prior to this application. Detail below. Co-mediation can be documented as either experience or observation – do not count the same case twice. Complete on separate page if needed. Do not provide party names. e. Case Type Date Length of Time ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ f. 11. As a non-lawyer or non-Michigan licensed lawyer, completed on __________________________________ a 6-hour program addressing basic Michigan laws, rules, and guidelines governing civil actions. Trainer: ___________________________________________________________ Other Qualification Complete items 11a or 11b and 11c through 11e. a. Voluntary Facilitative Mediation Program Training – Completed a minimum 16-hour program prior to January 1, 2003. Attach copy of certificate and copy of training agenda. Specify the name of the trainer and dates of attendance. _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ b. Circuit Court Mediation – Completed a minimum 16-hour mediation training program and supplemental 8-hour program related to the training components of Section 2.1 completed before December 31, 2001. Attach copy of certificate and copy of training agenda. Specify the name of the trainer and dates of attendance. ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ c. If the training was completed more than 2 years prior to the application, completed 8 hours of advanced mediation training in the 2 years prior to this application. Specify type of training, dates and trainers and attach copy of certificate. _______________________________________________________________________________________________________ ________________________________________________________________________________________________________ d. Observed or co-mediated two general civil mediation proceedings. Specify dates and name of qualified * mediator who observed or co-mediated. Co-mediation can be documented as either experience or observation – do not count the same case twice. Do not include party names. Date Name of Qualified Mediator ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ e. Conducted under supervision or co-mediated one general civil mediation to conclusion. Specify date and name of qualified * mediator who observed or co-mediated. Co-mediation can be documented as either experience or observation – do not count the same case twice. Do not include party names. Date Name of Qualified Mediator ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ 4 American LegalNet, Inc. www.FormsWorkflow.com f. If not a lawyer, mediated at least 40 hours or 18 cases in the 2 years prior to this application. Detail below. Co-mediation can be documented as either experience or observation – do not count the same case twice. Complete on separate page if necessary. Do not provide party names. _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ 12. Renewing Application If the mediation training was completed more than 2 years prior to the application, completed 8 hours of advanced mediation training in the 2 years prior to this application. Specify type of training, dates and trainers and attach copy of certificate. _______________________________________________________________________________________________________ ________________________________________________________________________________________________________ CERTIFICATION I certify that I: a) meet the requirements for service under the Court’s mediator selection plan; b) will not discriminate against parties or attorneys on the basis of race, ethnic origin, gender, or other protected personal characteristic; and c) will comply with the Court’s ADR plan, orders of the Court regarding cases submitted to mediation, and the standards of conduct adopted by the State Court Administrative Office. My fee for services is: ________________________ per: ____________________ My practice specialty is: _____________________________________________________ ___________________________________ Date ________________________________________________________________________ Signature Please send this completed application to: Oakland County Case Management – ADR Office 1200 N Telegraph Rd Dept 404 Pontiac MI 48341-0404 5 American LegalNet, Inc. www.FormsWorkflow.com Civil Mediator Application – pro bono and observer/observee information will not affect the status of your application to be a mediator. Part C: Pro Bono and Observee/Observer Information Providing the following information is optional. Full name (first, middle initial, last) (print or type) 1. Bar no. (if applicable) P Once you have been fully qualified to be a mediator, and have completed 40 hours of experience or 18 cases: a. b. Would you be willing to be a pro bono observer? Yes ________ c. 2. Are you willing to be observed by a potential mediator? Yes________ No_________ Would you be willing to be an observer under terms and conditions you agree upon with the potential mediator you are observing? Yes ________ No _________ No _________ Would you be willing to accept a pro bono appointment from the court to serve as a mediator once a year? Yes ________ No _______ ___________________________________ Date ________________________________________________________________________ Signature 6 American LegalNet, Inc. www.FormsWorkflow.com Civil Mediator Application – gender and race information to be maintained separately form pages 1, 2, 3, 4 and 5 of application Part D: Gender and Race Information Providing the following information is optional. It is requested in accordance with MCR 2.404(E)(1)(c) and will be maintained separately from your application. Full name (first, middle initial, last) (print or type) Bar no. (if applicable) P Check the boxes that apply to you. Gender: Female Male Race/Ethnicity: American Indian or Alaskan Native Asian or Pacific Islander Black/African American (non-Hispanic) Hispanic White/Caucasian (non-Hispanic) Other (specify): ____________________________________________ 7 American LegalNet, Inc. www.FormsWorkflow.com