UNITED STATES BANKRUPTCY COURT SOUTHERN DISTRICT OF NEW YORK x In Re: APPLICATION FOR INCLUSION ON COURT'S REGISTER OF MEDIATORS x I, the undersigned, hereby apply for inclusion on the Register of Mediators for the United States Bankruptcy Court for the Southern District of New York. In making this application, I certify under penalty of perjury that all of the following information is true and correct and that I meet the requirements of ¶ 2.0 The Mediator, as found in the Amended General Order of this court dated, December 1, 2009. , 1. I {insert name} will fully comply with the relevant provisions of the Bankruptcy Code and Federal Rules of Bankruptcy Procedure and this court's relevant Local Rules and General Orders. I maintain offices at {insert complete office address} and my contact information is {insert telephone number, fax number and email address}. 2.1 I have been licensed or accredited under the laws of the United States, New York, or any other state, in the professions or specialties listed below (e.g., attorney, accountant, real estate broker, appraiser, engineer, etc.) since the date indicated: Profession Accrediting Agency or Jurisdiction Date of Admission Revised 12/17/12 American LegalNet, Inc. www.FormsWorkFlow.com 2.2 I am, or have been, a member in good standing of the professional organizations listed below which apply to my aforementioned professions: Organization Date of Admission Active/Inactive 2.3 A general explanation of my experience in each of my aforementioned professions or specialties is listed below: 3.1 The following is a general statement concerning pertinent mediation experience that I have: 3.2 I have/have not participated in a mediation training program. The programs in which I have participated are described below (including course, program sponsor and hours): 4. experience: The following is a brief explanation of my pertinent bankruptcy Revised 12/17/12 American LegalNet, Inc. www.FormsWorkFlow.com 5. The following is a general explanation of any other pertinent experience, such as relevant business or legal activities, that I have: 6. I have: (a) never been suspended, disbarred or had any professional license revoked; (b) no pending adverse actions against any of my professional licenses; (c) never been convicted of a felony; and (d) never been sanctioned or reprimanded by any tribunal for unethical or unprofessional conduct, including a violation of Rule 11 or Rule 9011. (Should any of the above apply, please describe the circumstances on an attached page.) 7. I will not accept appointment as a mediator in any proceeding or matter unless at the time of appointment I would qualify as a "Disinterested person" as defined by 11 U.S.C. §101;I would not be disqualified pursuant to 28 U.S.C. §455 if I were a justice, judge, or magistrate; or I know of no other reason that would disqualify me as a mediator. In accordance with the court's amended general order M-390, each person certified as a mediator should take the oath or affirmation prescribed by 28 U.S.C. § 453 before serving as a mediator. Administration of the oath will be attested by affixing Revised 12/17/12 American LegalNet, Inc. www.FormsWorkFlow.com your signature to the attached copy titled Exhibit "A". After acceptance of appointment as a mediator, I will immediately contact the court to resign upon learning that I am no longer qualified to serve. Dated: 20 Signature* Print or Type Name and last four digits of SS # Address Telephone Number: E-mail Address: * I understand that if I am certified I may be asked to file this information in an electronic database. If asked I understand that I must comply with the request to be included in the register. Revised 12/17/12 American LegalNet, Inc. www.FormsWorkFlow.com Exhibit "A" OATH OF OFFICE I, , do solemnly swear (or affirm) that I will administer justice without respect to persons, and do equal right to the poor and to the rich, and that I will faithfully and impartially discharge and perform all the duties incumbent upon me as mediator under the Constitution and laws of the United States. So help me God. Dated: Signature: American LegalNet, Inc. www.FormsWorkFlow.com