APPLICATION FOR MEDIATION PANEL U.S. DISTRICT COURT - WESTERN DISTRICT OF NEW YORK 1) Applicant’s Full Name: Please contact me at my: Office Home Address: Tel.: Fax: Email: 2) Date admitted to practice before: A) B) C) United States District Court Western District of New York / Appellate Division of the Supreme Court of the State of New York / / / Are you presently engaged in the active practice of law in the Western District of New York? Yes 4) / The highest court of a State (if not admitted in New York) Court: 3) / No Formerly (last year of practice) Check your primary fields of specialization (not more than 3). 1. 2. 3. 4. 5. 6. 7. Admiralty Antitrust Banking Civil Rights Commercial Consumer Construction 1 American LegalNet, Inc. www.FormsWorkflow.com 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 5) Contract Copyright & Literary Corporation Employment Entertainment Environmental ERISA/Pension Funds Estate Planning General Practice Health Immigration Insurance International Labor Media Medical Malpractice Municipal Patent Product Liability Real Property RICO Act Secured Creditors Securities Sports Tax Technology/Intellectual Property Tort Trademark Other (please specify) State the percentage of your practice that consists of representing: Plaintiffs: 6) % Defendants: % If you have received training as a mediator within the last five years, set forth for each training the date, the provider, the course title and the number of course hours: (attach additional sheets, if needed) 2 American LegalNet, Inc. www.FormsWorkflow.com 7) If you have experience as a mediator, set forth the courts, entities and/or organizations for which you have served as a mediator and the total number of disputes you have mediated in the last two years: Disputes mediated in last two years: 8) I am willing to hear cases in: Buffalo 9) Rochester Both locations I am available to serve on short notice in the event that the mediator originally selected/appointed is not available. Yes No I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT (Applicant’s Signature) Date: Return Original Application To: Judy S. Hernandez, Staff Attorney United States District Court Western District of New York 68 Court Street - 5th Floor Buffalo, NY 14202 3 American LegalNet, Inc. www.FormsWorkflow.com