MC 281b � (6/19) � DOMESTIC RELATIONS MEDIATOR APPLICATION, Page 1 of 3 en-USApproved, SCAOen-USDOMESTIC RELATIONS MEDIATOR APPLICATIONen-USTo be eligible to serve as a domestic relations mediator, you must meet the training and experience criteria specified en-USeither in MCR 3.216(G) or in the SCAO Mediation Training Standards and Procedures pursuant to MCR 3.216(G)(2).en-USService as a case evaluator under MCR 2.403 does not constitute a qualification for serving as a mediator. Refer to the en-USMediation Training Standards and Procedures for further information about minimum qualifications.en-USNote: Except for Part B, the information provided in this application is available to the public for inspection.en-USPlease type or print neatly.en-US en-US1. Full name (first, middle initial, last)en-US2. Bar no. if applicableen-USPen-US3. Address where you can be contacteden-US4. Telephone no.en-US( )en-US5. Fax no.en-US( )en-US6. E-mail addressen-USPart A: Domestic Relations Mediator Qualificationsen-US en-USComplete items 7,8, and 9 as appropriate. 7. � Is this a � new application? � renewal? � en-USContact the local court for renewal requirements before submitting this application. 8. � � a. � Completed a 4-hour domestic violence training program approved by the State Court Administrative Office on or before � December 31, 2012. The program was completed on en-USDateen-US . � � b. � Completed an 8-hour domestic violence training program approved by the State Court Administrative Office after � December 31, 2012. The program was completed on en-USDateen-US . 9. � Qualification through State Court Administrative Office (SCAO)-Approved Training or Association for Conflict � � Resolution (ACR)-Approved Training. � a. � At least 40 hours of SCAO or ACR-approved training completed on en-USDateen-US . en-USAttach copy of certificate and training agenda. � Trainer: en-US � If either training was completed more than 2 years before applying, the applicant must have completed 8 hours of advanced � mediation training in the 2 years before applying. en-USSpecify type of training, dates, and trainers, and attach copy of certificate. � en-US � b. � � Licensed in appropriate field. en-USSpecifyen-US. en-US � � Master or graduate degree in appropriate field. en-USAttach copy of diploma. � � 5-years222 experience in family counseling. en-USDetail below. Complete on separate page if needed. � en-US � en-US � en-US en-UScontinued on page 2 American LegalNet, Inc. www.FormsWorkFlow.com MC 281b � (6/19) � DOMESTIC RELATIONS MEDIATOR APPLICATION, Page 2 of 3 en-USDomestic Relations Mediator Application, continued from page 1en-USPart A: Domestic Relations Mediator Qualificationsen-US (continued) 9. � c. � Observed two domestic relations mediation proceedings. en-USSpecify dates and mediator names and attach verification. Do not provide party � names. � en-US � en-US � � d. � Conducted one domestic relations mediation to conclusion. en-USSpecify date and name of mediator serving as supervisor and attach � verification. Do not provide party names. � en-US � � e. � Requesting waiver of degree requirements: Completed 80 hours or 20 cases in domestic relations mediation. en-USDetail � below. Complete on separate page if needed. Do not provide party names. � en-US � � � en-US en-USI certify that I: (a) meet the requirements for service under the court222s mediator selection plan; (b) will not discriminate againsten-USparties or attorneys on the basis of race, ethnic origin, gender, or other protected personal characteristic; and (c) will complyen-USwith the court222s ADR plan, orders of the court regarding cases submitted to mediation, and the standards of conduct adopted byen-USthe State Court Administrator. My hourly fee is $ en-US en-US . en-USDate � en-USSignatureen-USCERTIFICATION American LegalNet, Inc. www.FormsWorkFlow.com MC 281b � (6/19) � DOMESTIC RELATIONS MEDIATOR APPLICATION, Page 3 of 3 en-USDomestic Relations Mediator Application - gender and race information to be maintained separately from pages 1 and 2 of en-USapplication en-USFull name (first, middle initial, last) (print or type)en-USBar no. (if applicable)en-USPen-USPart B: Gender and Race Informationen-USProviding the following information is optional. It is requested in accordance with MCR 3.216(F)(1)(c) and will be maintaineden-USseparately from your application.en-USCheck the boxes that apply to you.en-USGender: � � Female � en-US Maleen-USRace/Ethnicity: � American Indian or Alaskan Native � Asian or Pacific Islander en-US Black/African American (non-Hispanic) � Hispanic � White/Caucasian (non-Hispanic) � Other (specify): en-USPart C: Pro Bono and Observee/Observer Informationen-USProviding 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? Yes � en-US No b. Are you willing to observe a prospective mediator in mediation pro bono? Yes � en-US No 2. Are you willing to accept appointment from the court to serve as a pro bono mediator once a year? Yes � en-US Noen-USPart D: Evaluative Mediation 1. Are you willing to provide evaluative mediation in accordance with MCR 3.216(I)? Yes � en-US No American LegalNet, Inc. www.FormsWorkFlow.com