UNITED STATES DISTRICT COURT EASTERN DISTRICT OF MISSOURI NEUTRAL'S APPLICATION FORM I am applying for certification as a neutral with the United States District Court for the Eastern District of Missouri, in accordance with rules of the Eastern District of Missouri. The following information is supplied in support of this application: 1. 2. 3. 4. 5. 6. 7. 8. Name (please print): (Last) (First) (M.I.) Firm Name: Address: (Street Number) (City) (State) (Zip + Ext.) Office Phone Number/Fax: Email address: Missouri Bar ID Number: Date admitted to: The Missouri Bar: Bar of this Court Have you been admitted to practice law in the highest court of any state or the District of Columbia for at least five (5) years? D Yes D No Are you currently a member in good standing in each jurisdiction where admitted to practice law? D Yes D No Please list the jurisdictions in which you currently are admitted to practice/and have held a valid license to practice law for at least five (5) years)? 9. 10. 1 American LegalNet, Inc. www.FormsWorkFlow.com 11. If any response to the following questions is YES, please explain circumstances on a separate sheet and attach. a.) Have you ever been disciplined for violation of any code of professional ethics or responsibility? D Yes D No b.) Have you ever been found guilty of a felony? D Yes D No c.) Have you ever been found liable for fraud or any other intentional tort? D Yes D No d.) Have you ever had a professional license revoked or suspended other than for non-payment of dues? D Yes D No e.) Have any legal malpractice judgments been entered against you? D Yes 12. I am seeking certification to serve as a neutral in: (Select One) D Mediation 13. D Early Neutral Evaluation D Both D No My standard hourly fee for services: Per hour as a neutral in Mediation Per hour as a neutral in ENE Additional fees 14. I have completed at least 32 hours of accredited continuing legal education training in mediation. The course work has included all of the following content: (1) conflict resolution and mediation theory, including causes and dynamics of conflict, interest-based versus positional bargaining, negotiating theory, and models of conflict resolution; (2) mediation and co-mediation skills and techniques, including information gathering skills, conflict management skills, listening skills, negotiations techniques, power issues, caucusing, management of joint session, cultural and gender issues, and modeling with self-represented as well as represented individuals; (3) mediator conduct, including conflicts of interest, confidentiality, impartiality, ethics and standards of practice; and (4) mediation simulations or role play activities. 2 American LegalNet, Inc. www.FormsWorkFlow.com 15. Please list training or professional education completed by you that qualifies you as a neutral pursuant to Local Rule 16-6.03(A): (Please attach certificates of completion.) Session Title Sponsor Location Dates CLE Hours 16. How many of the training hours listed above have been approved by the Missouri Bar for CLE credit and, if not approved by Missouri, what jurisdiction has approved these CLE hours? I have observed as a non-participant at least two mediations conducted by a mediator who has completed twenty-five (25) mediations and is either certified under this rule or qualified under Missouri Supreme Court Rule 17. D Yes D No Name of Mediator(s) Dates of observations: 17. 18. I agree to accept appointment by the Court as a pro bono neutral for reduced or no compensation from a party who has qualified pursuant to Local Rule 16-6.03(C)(2). D Yes D No 3 American LegalNet, Inc. www.FormsWorkFlow.com 19. I agree to complete four (4) hours of accredited continuing legal education in alternative dispute resolution on or before January 31 of each odd-numbered year with the initial reporting period beginning in 2019 for the two preceding years. D Yes D No 20. After completing twenty-five (25) mediations, I agree to be observed by interested individuals who are qualified for certification under Local Rule 16-6.03. D Yes D No 21. List the courts and professional organizations in which you currently hold certifications as a neutral, mediator, arbitrator or other ADR service provider: 22. In the space below, briefly describe your experience, qualifications, special areas of expertise, and any other reasons why you should be selected as a certified neutral. Signature Date Print Name NOTE: This form will be made available to parties to assist them in selecting a neutral. FOR COURT USE ONLY Date Certified by the Court as a Neutral: Amended 12/20/2016 4 American LegalNet, Inc. www.FormsWorkFlow.com