Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Application Form For Applicants For Inclusion On Mediation Register (Non Lawyer Professionals Only) Form. This is a New York form and can be use in Bankruptcy Court Federal.
Loading PDF...
Tags: Application Form For Applicants For Inclusion On Mediation Register (Non Lawyer Professionals Only), New York Federal, Bankruptcy Court
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
:
Index No.
Calendar No.
Application Form for:
JUDICIAL SUBPOENA
Plaintiff(s)
Applicants for Inclusion on Mediation Register
-against(Non-Lawyer Professionals: Only)
:
:
United States Bankruptcy Court
Defendant(s)
:
. .Eastern .District . . .New .York . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . of . . . . . . . .
----------------------------------------------------x
In re:
THE PEOPLE OF THE STATE OF NEW YORK
TO
APPLICATION FOR INCLUSION ON
COURT’S REGISTER OF MEDIATORS
[For Non-Lawyer Professionals Only]
GREETINGS:
----------------------------------------------------x
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable I, the undersigned, hereby apply the inclusion on the Register of Mediators for the
at for
Court
located at
County ofStates Bankruptcy Court for the Eastern District of New York.
United
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
or adjourned date, to testify and give evidence as a witness in this action on the part of the
1.
Full name of applicant (list any former names and dates used):
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
2. Present business address and phone:
result of your failure to comply.
Witness, Honorable
, one of the Justices of the
Court in
day of
, 20
3. County,
I consider myself a professional in the following field:
(Attorney must sign above and type name below)
4.
Please provide (in reverse chronological order) a brief description of all
significant full-time employment experiences since graduation from college:
Attorney(s) for
5. Please list all colleges and professional schools that you attended, including
Office what degrees were
(i) the dates of attendance, (ii) the addresses of the school, (iii) and P.O. Address received, and
(iv) the date on which any degrees were received:
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
American LegalNet, Inc.
www.USCourtForms.com
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
:
Index No.
Calendar No.
:
6. Please list any special honors, scholarships,JUDICIAL honorary degrees
fellowships, SUBPOENA
Plaintiff(s)
and/or honorary society memberships that you received:
-against-
:
:
:
7. List all licenses or professional accreditations that you have received or been
Defendant(s)
:
. .awarded. .in. .the. .United. .States . or . elsewhere,. .together . with the dates of such licenses or
....... . .. ..... ..... .. ......... ....... .
accreditations: (If there have been any lapses or suspensions in such accreditations, please so
state and explain.)
THE PEOPLE OF THE STATE OF NEW YORK
TO
8.
Please provide a brief description of your business practice:
GREETINGS:
9. Please provide a brief description of your experience and familiarity with
WE law:
bankruptcyCOMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
located at
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
or adjourned date, to testify and give evidence as a witness in this action on the part of the
10. Please provide a brief description of your experience as a mediator or any
other alternative dispute resolution experience that you may have:
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
result of your failure to comply.
11. Please describe all mediation training programs and/or courses that you
have taken, setting forth (i) the title of the course, (ii) the name of the school or instructor, (iii) the
Witness, of the program, (iv) the date(s) of the courses and/orone of the Justices ofnumber
, programs, (v) the the
sponsor, if any, Honorable
Court in
County,
day of
, 20
of classroom hours, and (vi) the certification, if any, that was awarded:
(Attorney must sign above and type name below)
12. Please list all professional organizations of which you are a member,
including the dates of membership and whether or not you are an active member:
Attorney(s) for
13. Please list any other pertinent experience, including, for example, relevant
Office and P.O. experience:
business or legal activities, public speaking activities and/or teaching Address
Page 2 of 4
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
American LegalNet, Inc.
www.USCourtForms.com
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
:
Index No.
Calendar No.
:
14. Please indicate “yes” or “no” as to whether JUDICIAL SUBPOENA
you have
Plaintiff(s)
-against:
(a) ever been suspended, disbarred, or had any professional license revoked:
(b) any pending adverse actions against any of your professional licenses:
_____
:
(c) ever been convicted of a felony:
(d) ever been sanctioned or reprimanded by any tribunal for unethical or unprofessional
:
conduct:
Defendant(s)
:
......................................................
If your answer is “yes” to any of the questions set forth in question 14, please
explain in detail:
THE PEOPLE OF THE STATE OF NEW YORK
TO
15. By making this application, I hereby certify that, if approved to serve as a
mediator, I will not accept appointment as a mediator in any proceeding or matter unless at the
time of appointment, I would (i) qualify as a “Disinterested Person” as defined by 11 U.S.C. §
101; (ii) not
GREETINGS: be disqualified pursuant to 28 U.S.C. § 455 assuming the same were to apply to
a mediator; (iii) know of any other reason that would disqualify me as a mediator. I further certify
WE COMMAND YOU, the court to resign upon being laid aside, you and longer serve as
that I will immediately contactthat all business and excuseslearning that I could noeach of you attend before
,
the Honorable because of disqualifications.
at the
Court
a mediator
located at
County of
in room
, on
day of
, 20
o'clock to the noon, and of the
16. theBy making this application, I, at
hereby consentin the disclosure at any recessed
or adjourned date, to testify and give evidence as a witness in this action on the part of the
information contained herein, whether it be to Court personnel, the parties and/or their
representatives, and to the public.
Your failure toBy making this application,punishableconsent to any inquiries that mightyou liable to
17. comply with this subpoena is I hereby as a contempt of court and will make be
the partyconcerning the veracity or accuracy of the a maximum penalty of $50 and which the Court
on whose behalf this subpoena was issued for information set forth herein, all damages sustained as a
made
result of your failure to comply.
or any authorized Court personnel may make with any accrediting or licensing agency, any other
public or private institution or any other entity or person listed herein, and I agree to cooperate
Witness, Honorable
one of the Justices a the
with any such inquiry. I further agree that, if I fail to cooperate upon ,request, it may be of ground
Courtdisqualifying me as a mediator of removing 20 name from the Register of Mediators.
County,
day and
, my
for in
18. By making this application, I certify that I will fully comply with the relevant
provisions of the Bankruptcy Code, the Federal Rules of (Attorney must sign above and type name below)
Bankruptcy Procedure, and this Court’s
Local Rules and General Orders.
Attorney(s) for
19. By making this application, I certify that I meet the qualification requirements
set forth in the E.D.N.Y. Local Bankruptcy Rule 9019-1 governing mediation and mediators,
except to the extent set forth below:
Office and P.O. Address
Page 3 of 4
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
American LegalNet, Inc.
www.USCourtForms.com
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
:
Index No.
Calendar No.
:
20. I understand that I may be requested from time to time to serve as mediator
JUDICIAL SUBPOENA
Plaintiff(s)
or mediation advocate in a case on a pro bono basis. If asked, I am willing to undertake three
-against:
such assignments during the term of my appointment in cases pending in:
Brooklyn
Central Islip
:
:
21. I certify that I have not been affiliated with or employed by the Court during
Defendant(s)
:
the 36-month period preceding the date of this Application.
......................................................
22.
I declare under penalty of perjury that the information provided in this
THE PEOPLE is true and correct. NEW YORK
application OF THE STATE OF
TO
Dated:
GREETINGS:
WE COMMAND YOU, that all businessSignature ofbeing laid aside, you and each of you attend before
and excuses Applicant
,
the Honorable
at the
Court
located at
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
or adjourned date, to testify and give evidence as a witness in this action on the part of the
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
result of your failure to comply.
Witness, Honorable
Court in
County,
, one of the Justices of the
day of
, 20
(Attorney must sign above and type name below)
Attorney(s) for
Office and P.O. Address
Page 4 of 4
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
American LegalNet, Inc.
www.USCourtForms.com
