Approved, SCAO CIVIL MEDIATOR APPLICATION To be eligible to serve as a general civil mediator, you must meet the training and experience criteria specified either in MCR 2.411(F)(2) or in the SCAO Mediation Training Standards and Procedures pursuant to MCR 2.411(F)(3). Service as a case evaluator under MCR 2.403 does not constitute a qualification for serving as a mediator. Refer to the Mediation Training Standards and Procedures for further information about minimum qualifications. Note: Except for Part B, 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) 3. Address where you can be contacted 4. Telephone no. 5. Fax no. 6. E-mail address 2. Bar no. if applicable P ( ) ( ) Part A: General Civil Mediator Qualifications Complete item 7 and either item 8, 9, or 10 as appropriate. 7. 8. Is this a new application? renewal? Contact the local court for renewal requirements before submitting this application. Qualification through State Court Administrative Office (SCAO) Approved Training a. SCAO-approved training completed on Date . Attach copy of certificate. Trainer: b. Juris doctorate. Attach copy of diploma if not a licensed attorney. Attach copy of diploma. Detail below. Complete on separate page if needed. Graduate degree in conflict resolution. 40 hours of mediation experience in the past 2 years. c. Observed two general civil mediation proceedings. Specify dates and mediator names and attach verification. Do not provide party names. d. Conducted one general civil mediation to conclusion. not provide party names. Specify date and name of mediator serving as supervisor and attach verification. Do 9. Qualification by Community Dispute Resolution Program (CDRP) Training a. Michigan CDRP training completed on Date . Attach copy of certificate. Trainer: If the training was completed more than 2 years before applying, applicant must have completed 8 hours of advance mediation training in the 2 years before applying. Specify type of training, dates, and trainers, and attach copy of certificate. MC 281a (3/13) continued on page 2 CIVIL MEDIATOR APPLICATION, Page 1 of 3 MCR 2.411(E) American LegalNet, Inc. www.FormsWorkFlow.com Civil Mediator Application, continued from page 1 Part A: General Civil Mediator Qualifications (continued) 9. b. Observed two general civil mediation proceedings. Specify dates and mediator names and attach verification. Do not provide party names. c. Conducted one general civil mediation to conclusion. not provide party names. Specify date and name of mediator serving as supervisor and attach verification. Do d. If not an attorney or a person holding a juris doctorate or graduate degree in conflict resolution, mediation, or comediation, applicant must have mediated at least 40 hours or 18 cases in the 2 years before applying. Detail below. Complete on separate page if needed. Do not provide party names. 10. Qualification by Training Outside of Michigan a. Completed a comprehensive training course of at least 40 hours designed for general civil case mediation. Attached are: (1) a certificate of completed training, (2) a copy of the training agenda, (3) the name of the trainer, and (4) the dates of attendance. b. If the training was completed more than 2 years before applying, applicant must have completed at least 8 hours of advanced mediation training in the 2 years before applying. Specify type of training, dates, and trainers, and attach copy of certificate. c. Observed two general civil mediation proceedings. Specify dates and mediator names and attach verification. Do not provide party names. d. Conducted one general civil mediation to conclusion. not provide party names. Specify date and name of mediator serving as supervisor and attach verification. Do e. If not an attorney or a person holding a juris doctorate or graduate degree in conflict resolution, mediation, or comediation, applicant must have mediated at least 40 hours or 18 cases in the 2 years before applying. Detail below. Complete on separate page if needed. Do not provide party names. 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 Administrator. My hourly fee is $ . Date MC 281a (3/13) Signature CIVIL MEDIATOR APPLICATION, Page 2 of 3 MCR 2.411(E) American LegalNet, Inc. www.FormsWorkFlow.com Civil Mediator Application - gender and race information to be maintained separately from pages 1 and 2 of application Full name (first, middle initial, last) (print or type) Bar no. (if applicable) P Part B: Gender and Race Information Providing the following information is optional. It is requested in accordance with MCR 2.411(E)(1)(c) and will be maintained separately from your application. Check the boxes that apply to you. Gender: Female Race/Ethnicity: American Indian or Alaskan Native Asian or Pacific Islander Black/African American (non-Hispanic) Hispanic White/Caucasian (non-Hispanic) Other (specify): Male Part C: Observer Information and Pro Bono Services Providing the following information is optional and will be maintained separately from your application. 1. Once you have been qualified by the court to serve as a mediator: a. Are you willing to be observed by a prospective mediator? b. Are you willing to observe a prospective mediator in mediation pro bono? 2. Are you willing to accept appointment from the court to serve as a pro bono mediator once a year? Yes Yes No No Yes No MC 281a (3/13) CIVIL MEDIATOR APPLICATION, Page 3 of 3 MCR 2.411(E) American LegalNet, Inc. www.FormsWorkFlow.com