IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF NEBRASKA MEDIATOR RENEWAL APPLICATION Name: Address: Phone: Fax: E-Mail: I have completed mediation training pursuant to the Nebraska Dispute Resolution Act, and I am associated with the following state mediation center(s): Center Name Center Name Center Address Center Address I have been admitted to the practice of law in the following state(s) since my last approval: state month, year state month, year state month, year I am currently in good standing as an attorney before the courts of Nebraska: yes no 1 American LegalNet, Inc. www.FormsWorkflow.com I am currently in good standing as an attorney before the United States District Court for the District of Nebraska: yes no Other training in the practice of mediation which I have received since my last approval is detailed below. (State the date, place, sponsor, trainers, subjects covered, and number of hours involved for each training session you have completed; you need not repeat training which has been described in previous applications): 2 American LegalNet, Inc. www.FormsWorkflow.com Since my last approval, I have mediated the following disputes (State the date, place, which were not then in litigation: parties, nature of dispute, number of mediation sessions involved, and whether the mediation was successful in resolving the dispute. You need not repeat mediations reported in an earlier application to this court). 1. 2. 3. 4. 5. 3 American LegalNet, Inc. www.FormsWorkflow.com Since my last approval, I have mediated the following disputes which were in litigation at the time of the mediation. (State the date, place, parties, attorneys, nature of dispute, court, number of mediation sessions required, and whether the dispute was successfully resolved as a result of the mediation. You need not repeat information supplied in an earlier application to this court. Include mediations referred from federal court, as well as others. Attach additional pages if necessary.): 1. 2. 3. 4. 4 American LegalNet, Inc. www.FormsWorkflow.com 5. Since my last approval, I have participated in the following: Annual Mediation Workshop in July, 1996. Annual Mediation Skills Workshop in May, 1997. Annual Mediation Skills Workshop in April, 1998. Annual Mediation Skills Workshop in July, 1999. Annual Mediation Skills Workshop in September, 2000. _____ Annual Mediation Skills Workshop in November, 2002. Continuing Education Courses Completed in Mediation (list title and sponsor of the workshop, date, location, subjects covered, and number of hours): 5 American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS FOR DECLARATION OF COMPETENCE Lawyers representing clients in federal litigation want to know your knowledge and experience level in the substantive law of their cases. Sometimes a background of specialized study, or representing a client in only one major cases is enough to sufficiently learn the law for mediation purposes; other times, significant trial and pretrial litigation experience is necessary to be adequately conversant in the subject matter to handle a mediation. While “law review expertise” is not necessary, you should be knowledgeable enough about the substantive law that you can converse with the lawyers about the elements of the claim and the various defenses that might apply, as well as the practical aspects of settling cases in that subject area. Please think carefully about your personal level of competence in these subject areas, and declare only those areas in which you feel confident representing yourself to fellow lawyers as competent to mediate, as follows: Designate with a “1" only those areas in which you feel comfortable as your primary subject areas of competence. You will be contacted 6 American LegalNet, Inc. www.FormsWorkflow.com to mediate cases in those subject areas. If there are other areas of law in which you have some competence, but do not feel comfortable mediating alone, you may designate those with a “2.” You may be asked to co-mediate cases in those subject areas with another mediator who has designated that area as one of primary competence. DECLARATION OF COMPETENCE I have carefully reviewed my personal level of knowledge and experience in the subject areas listed below. I have sufficient knowledge and experience litigating and/or mediating cases in the following areas of law that I am competent to handle federal case mediations involving these subject areas: 7 American LegalNet, Inc. www.FormsWorkflow.com CONTRACT Insurance Marine Miller Act Negotiable Instrument Recovery of Overpayment & Enforcement of Judgment ___ 151 Medicare Act ___ 152 Recovery of Defaulted Student Loans (Excl. Veterans) ___ 153 Recovery of Overpayment of Veteran’s Benefits ___ 160 Stockholders’ Suits ___ 190 Other Contract ___ 195 Contract Product Liability REAL PROPERTY ___ 210 Land Condemnation ___ 220 Foreclosure ___ 230 Rent Lease & Ejectment ___ 240 Torts to Land ___ 245 Tort Product Liability ___ 290 All Other Real Property TORTS Personal Injury ___ 310 Airplane ___ 315 Airplane Product Liability ___ 320 Assault, Libel & Slander ___ 330 Federal Employers’ Liability ___ 340 Marine ___ 345 Marine Product Liability ___ 350 Motor Vehicle ___ 355 Motor Vehicle Product Liability ___ 360 Other Personal Injury ___ 362 Personal Injury - Medical Malpractice ___ 365 Personal Injury - Product Liability ___ 368 Asbestos Personal Injury Product Liability Personal Property ___ 370 Other Fraud ___ 371 Truth in Lending ___ 380 Other Personal Property Damage ___ 385 Property Damage Product Liability CIVIL RIGHTS ___ 441 Voting ___ 442 Employment ___ 443 Housing/Accommodations ___ 444 Welfare ___ 440 Other Civil Rights BANKRUPTCY ___ 422 Appeal 28 USC 158 ___ 423 Withdrawal 28 USC 157 PRISONER PETITIONS ___ 510 Motions to Vacate Sentence Habeas Corpus: ___ 530 General ___ 535 Death Penalty ___ ___ ___ ___ ___ PRISONER PETITIONS - CONTINUED ___ 540 Mandamus & Other ___ 550 Civil Rights ___ 555 Prison Condition FORFEITURE/PENALTY ___ 610 Agriculture ___ 620 Other Food & Drug ___ 625 Drug Related Seizure of Property 21 USC 881 ___ 630 Liquor Laws ___ 640 R.R. & Truck ___ 650 Airline Regs. ___ 660 Occupational Safety/Health ___ 690 Other LABOR ___ 710 Fair Labor Standards Act ___ 720 Labor/Mgmt. Relations ___ 730 Labor/Mgmt. Reporting & Disclosure Act ___ 740 Railway Labor Act ___ 790 Other Labor Litigation ___ 791 Empl. Ret. Inc. Security Act PROPERTY RIGHTS ___ 820 Copyrights ___ 830 Patent ___ 840 Trademark SOCIAL SECURITY ___ 861 HIA (1395ff) ___ 862 Black Lung (923) ___ 863 DIWC/DIWW (405(g)) ___ 864 SSID Title XVI ___ 865 RSI (405(g)) FEDERAL TAX SUITS ___ 870 Taxes (U.S. Plaintiff or Defendant) ___ 871 IRS - Third Party 26 USC 7609 OTHER STATUTES ___ 400 State Reapportionment ___ 410 Antitrust ___ 430 Banks and Banking ___ 450 Commerce/ICC Rates/etc. ___ 460 Deportation ___ 470 Racketeer Influenced & Corrupt Org. ___ 810 Selective Service ___ 850 Securities/Commodities/Exchange ___ 875 Customer Challenge 12 USC 3410 ___ 891 Agricultural Acts ___ 892 Economic Stabilization Act ___ 893 Environmental Matters ___ 894 Energy Allocation Act ___ 895 Freedom of Information Act ___ 900 Appeal of Fee Determination Under Equal Access to Justice ___ 950 Constitutionality of State Statutes ___ 890 Other Statutory Actions 110 120 130 140 150 8 American LegalNet, Inc. www.FormsWorkflow.com I _____ am or _____ am not willing to travel to other parts of Nebraska to mediate cases in my primary subject areas of competence. I _____ am or _____ am not willing to travel to other parts of Nebraska to mediate cases in my secondary subject areas of competence. Are you willing to have your application placed on the court’s web page? _____ yes or _____ no , do hereby swear/affirm that I, the information provided by me on the preceding application is true and correct, to the best of my knowledge and belief. Subscribed and sworn to/affirmed before me this , day of . Clerk/Deputy Clerk/Notary Public [seal/stamp] 9 American LegalNet, Inc. www.FormsWorkflow.com OATH I, , do solemnly swear/affirm that I do meet the qualifications required by the Mediation Plan for the United States District Court for the District of Nebraska, and that I will promptly, faithfully and impartially discharge the duties of mediator in accordance with the Mediation Plan for the United States District Court for the District of Nebraska, applicable laws of the State of Nebraska, and the rules and orders of this court. of Subscribed and sworn to/affirmed before me this , . day Clerk/DeputyClerk/Notary Public [seal/stamp] from Application has been approved, for a period of five (5) years (date) to (date). Denise M. Lucks,Clerk United States District Court By Deputy Clerk [seal/stamp] 10 American LegalNet, Inc. www.FormsWorkflow.com