APPLICATION FOR APPOINTMENT AS ALTERNATIVE DISPUTE RESOLUTION (ADR) ARBITRATOR/MEDIATOR/EVALUATOR IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF NEW YORK I AM APPLYING FOR APPOINTMENT AS: *Note - You m ay apply for one or all of the following program s 9 ARBITRATOR (LR 83.7) 9 MEDIATOR (LR 83.11-1) 9 EARLY NEUTRAL EVALUATOR (LR 83.12-1) 1. NAME: OFFICE ADDRESS: SOCIAL SECURITY NUMBER: TAX I.D. NUMBER: OFFICE PHONE: 2. DATE ADMITTED TO NEW YORK STATE BAR: DATE ADMITTED TO PRACTICE BEFORE THE NORTHERN DISTRICT OF NEW YORK: BAR ROLL# 3. DATE ADMITTED TO PRACTICE BEFORE THE HIGHEST COURT OF A STATE (OTHER THAN NEW YORK): COURT: DATE OF ADMISSION: 4. SET FORTH BRIEFLY IN CHRONOLOGICAL ORDER, WITH DATES, THE NATURE OF YOUR PRACTICE OF LAW SINCE ADMISSION TO THE BAR: American LegalNet, Inc. www.FormsWorkflow.com 5. ARE YOU PRESENTLY ENGAGED IN THE ACTIVE PRACTICE OF LAW IN THE NORTHERN DISTRICT OF NEW YORK? YES: NO: 6. STATE BRIEFLY THE NATURE OF YOUR PRESENT PRACTICE: 7. WHICH OF THE FOLLOWING BEST DESCRIBES YOUR PRESENT PRACTICE OF LAW? CHECK ONE 9(A) MY PRACTICE PRIMARILY CONSISTS OF REPRESENTING DEFENDANTS 9(B) MY PRACTICE PRIMARILY CONSISTS OF REPRESENTING PLAINTIFFS 9(C) MY PRACTICE CANNOT BE DESIGNATED AS EITHER (A) OR (B) 8. IF YOU CHECKED 7 (A) OR (B), WILL YOU REPRESENT TO THE COURT THAT YOU WILL BE ABLE TO ACT AS A MEMBER OF THE ALTERNATIVE DISPUTE RESOLUTION PANEL, AND JUDGE WITHOUT BIAS, PREJUDICE, FAVOR AS TO EITHER THE PLAINTIFF OR DEFENDANT IN ANY CASE TO WHICH YOU ARE ASSIGNED? YES: NO: 9. PLEASE LIST THE NAME(S) OF A JUDGE, OR JUDGES (INCLUDING BANKRUPTCY AND MAGISTRATE-JUDGES) OF THIS COURT BEFORE WHOM YOU HAVE APPEARED OR WHO OTHERWISE MAY HAVE KNOWLEDGE OF YOUR QUALIFICATIONS. 10. IF YOU HAVE NOT NAMED ANY JUDGE OF THIS COURT IN ANSWER TO QUESTION #9, PLEASE LIST ANY OTHER FEDERAL JUDGES OR STATE JUDGES BEFORE WHOM YOU HAVE APPEARED OR WHO MAY OTHERWISE HAVE KNOWLEDGE OF YOUR QUALIFICATIONS. American LegalNet, Inc. www.FormsWorkflow.com 11. HAVE YOU EVER BEEN DISCIPLINED BY ANY COURT OR ADMINISTRATIVE OFFICE OF THE COURT? IF “YES”, GIVE DETAILS. YES: 12. HAVE YOU EVER SERVED AS AN ARBITRATOR/MEDIATOR/EVALUATOR IN THE FEDERAL COURT SYSTEM? IF “YES” PLEASE STATE WHERE AND WHEN. YES: 13. NO: HAVE YOU EVER SERVED AS AN ARBITRATOR/MEDIATOR/EVALUATOR IN ANY STATE COURT? IF “YES” PLEASE STATE WHERE AND WHEN. YES: 14. NO: NO: HAVE YOU EVER REPRESENTED A PARTY IN A CASE THAT WENT TO ANY FORM OF ALTERNATIVE DISPUTE RESOLUTION (ADR)? IF SO, CHECK: 9 FEDERAL 9STATE YEAR: WHAT COURT: TYPE OF ADR FORUM: 15. PLEASE SET FORTH ANY ADDITIONAL INFORMATION YOU BELIEVE WOULD BEAR UPON YOUR QUALIFICATIONS TO SERVE AS AN ARBITRATOR/MEDIATOR/EVALUATOR American LegalNet, Inc. www.FormsWorkflow.com 16. IN THE EVENT THAT YOU ARE APPOINTED, WOULD YOU BE WILLING ON OCCASION TO SERVE ON “SHORT NOTICE” IN SITUATIONS WHERE, FOR SOME REASON, THE PERSON ORIGINALLY APPOINTED IS NOT AVAILABLE? YES: 17. NO: PLEASE CHECK THE DIVISIONS WHERE YOU WOULD BE WILLING TO SIT AS AN ADR APPOINTEE: *NOTE: YOU W ILL NORMALLY BE ASKED TO SERVE IN THE CITY W HERE YOU MAINTAIN YOUR PRACTICE, BUT OCCASIONS MAY ARISE W HEN THE COURT W ILL NEED ADR APPOINTEES FROM OTHER LOCATIONS. ALBANY: UTICA: BINGHAMTON: SYRACUSE: WATERTOWN: I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT. SIGNATURE DATE: *PLEASE COMPLETE THE ATTACHED REQUEST FOR BIOGRAPHICAL DATA. American LegalNet, Inc. www.FormsWorkflow.com REQUEST FOR BIOGRAPHICAL SKETCH RE: ADR APPLICATIONS Kindly provide us with the attached biographical sketch to be included with your ADR applications. The biographical sketch is necessary to assist the Court in reviewing your applications, and later to assist litigants in making the selection of an Arbitrator, Mediator, or early neutral Evaluator to hear their case. Your biographical sketch will be sent to counsel for selection purposes in a case referred into the ADR program. Since your application will not be released when a strike list of randomly selected ADR appointees is sent to the parties and/or their attorneys, the biographical sketch will allow counsel of record to make the best choice on behalf of their client. Please return your completed ADR application and biographical sketch to: LAWRENCE K. BAERMAN, CLERK U.S. DISTRICT COURT James T. Foley U.S. Courthouse 445 Broadway, Room 509 Albany, NY 12207-2936 Attn.: Suzanne Gunter, ADR Administrator Sincerely, Lawrence K. Baerman, Clerk American LegalNet, Inc. www.FormsWorkflow.com ADR BIOGRAPHICAL SKETCH NORTHERN DISTRICT OF NEW YORK Name: Office Address: Phone/Fax: / Date and Place of Birth: Education: Undergraduate Degree: Date: Major: Law School: Date Admitted to New York Bar: Membership in Legal/Civil Organizations: ADR Experience: Nature of Practice/Area of Specialization: American LegalNet, Inc. www.FormsWorkflow.com