Application for Admission to Roster of Mediators for Civil, General Equity and Probate Cases Last Name Firm/Business Name Firm/Business Street Address (No PO Box) Telephone number Fax number City E-mail address State Zip code First Name Middle Initial Highest Degree Attained Name of Institution The following information will be used to determine eligibility: (See criteria on page 2) Year Area of Concentration Professional License(s) - specify type and when obtained. Have you ever been convicted of a crime or are criminal charges pending against you? (If yes, attach explanation.) Yes Number of Years of Experience No Bar admission year (if applicable) New Jersey Other States Date Mediation Completed Have you ever been disciplined in your profession or are disciplinary proceedings pending? (If yes, attach explanation.) Yes No Year of Admission to Professional Practice Cases You Mediated Within Last Year (attach additional sheet if necessary.) Case Name Docket Number Number of Hours of Mediation Training (attach copy of certificate of completion and attach additional sheet if necessary.) Provider(s) Course Title Date(s) Hours Are You a Court, State, or Local Government Employee or a Law Enforcement Officer? (If yes, attach explanation.) Hourly Fee (to be shared by the parties) Yes No The following information will be included on the roster if you are accepted: Counties in Which You Can Accept Cases Areas of Expertise for Mediation (check all that apply.) 997 Probate 998 General Equity 005 Civil Rights 156 Environmental Coverage Litigation 302 Tenancy 502 Book Account 505 Other Insurance Claim (including declaratory judgment actions) 506 PIP Coverage 508 Complex Commercial 513 Complex Construction 599 Contract/Commercial Transaction 602 Assault and Battery 603 Auto NegligencePersonal Injury 604 Medical Malpractice 608 Toxic Tort 609 Defamation 610 Auto NegligenceProperty Damage 616 Whistleblower (CEPA) 509 Employment (other than CEPA 618 Law Against or LAD) Discrimination 303 Mt. Laurel 510 UM or UIM Claim 605 Personal Injury 699 Tort Other 511 Action on a Negotiable 701 Actions in Lieu of 305 Construction 606 Product Liability Instrument Prerogative Writ 512 Lemon Law* 399 Real Property 607 Professional Malpractice * Must provide documentation that you have handled, as a practitioner, at least 15 lemon law cases in the past 5 years in order to list this case type. Descriptive Paragraph (Please provide a maximum of 560 characters about your mediation and other relevant professional experience. This information will be transferred directly to the roster if you are accepted.) I certify that the foregoing statements made by me are true, that I am in good standing in my profession, and that I will abide by program rules and guidelines. Date Signature Revised 09/01/2015, CN 10523-English Return this form to: Civil Practice Division, Administrative Office of the Courts, PO Box 981 Trenton, NJ 08625 Or Fax to (609) 777-0844 page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Roster of Mediators for Civil, General Equity and Probate Cases Criteria for Admission Mediation Training All applicants shall have completed a minimum of 40 hours in an approved mediation course as defined under Rule 1:40-12(b)(5). Applicants to the roster who have been trained in a 40-hour out-of-state mediation training or who completed the required 40-hour New Jersey mediation training more than five years prior to their application to the roster must complete the six-hour civil supplemental mediation course as defined under Rule 1:40-12(b)(8). Mentoring All applicants shall be mentored in at least two cases in the Law Division-Civil Part or Chancery DivisionGeneral Equity or Probate Part of the Superior Court for a minimum of five hours by a Civil Roster mediator mentor who has been approved in accordance with the "Guidelines for the Civil Mediation Mentoring Program" promulgated by the Administrative Office of the Courts. The list of approved mentors and guidelines for mentoring are available on the Judiciary's website, njcourts.com. Education/Professional Experience/Mediation Experience (as set forth under Rule 1:40-12(a)(3)) Applicants shall have: (1) at least a bachelor's degree; (2) five years of professional experience in the field of expertise in which they will mediate; and (3) evidence of completed mediation of a minimum of two Civil, General Equity or Probate Part cases within the last year. Please submit application for eligibility review prior to starting mentoring process. Other Requirements Counties in Which Mediator Can Accept Cases Mediators are expected to provide facilities at no cost to the parties in each county listed and cannot charge for travel time or expenses during the first two hours at no cost to the parties. Annual Continuing Mediator Education Attendance at a minimum of four hours of annual continuing mediation training is required as set forth under Rule 1:40-12(b)(2). Revised 09/01/2015, CN 10523-English American LegalNet, Inc. www.FormsWorkFlow.com page 2 of 2