Revised 03/07/2019, CN 10488 Criteria for Admission to the Roster of Mediators for Economic Aspects of Family Law Cases A Joint Credentials Committee of the Supreme Court Committee on Complementary Dispute American LegalNet, Inc. www.FormsW Revised 03/07/2019, CN 10488 New Jersey Judiciary Application for Admission to Roster of Mediators for Economic Aspects of Family Law Cases Last Name First Name Middle Name Firm / Business Name Firm / Business Address E mail City State Zip Code Telephone Number Fax Number Degrees Attained (Post High School) Year Area o f Concentration Name o f Institution Professional License(s) Admission Date License Number Have You Ever Been Disciplined In Your Profession? Year of Admission to Professional Practice Number of Years of Experience Bar Admission Year (If Yes, Attach Explanation) New Jersey: Yes No Other States: For Attorneys: Percent of Practice Devoted t o Matrimonial Law Certified Matrimonial Attorney Primary Counties o f Practice Yes No For Non-Attorneys: Percent of Time Devoted t o Family Matters Primary Counties o f Practice Mediation Training (attach additional sheet if necessary) Provider(s) Course Title Date(s) Hours Number of Years Doing Mediation Number of Mediations in Past 5 Years Hourly Fee Do You Have Malpractice Insurance ? $ Yes No I certify that the foregoing statements made by me are true and that I am in good standing in my profession. Date Signature Please attach the following: 1. Resume or Curriculum Vitae 2. Description of mediation training courses and copy of official training certificate 3. Descriptive paragraph (please provide a maximum of 50 words about your mediation and other relevantprofessional experience that will be transferred directly to the roster if you are accepted) 4. Subject area(s) of mediation experience 5. List of professional organizations in which you are an active member Return the ab ove five items and this form to: Joanne M. Dietrich Family Division Administrative Office of the Courts PO Box 983 Trenton, NJ 08625 American LegalNet, Inc. www.FormsWorkFlow.com