FORM 926 THIS SPACE FOR COURT USE ONLY Application for Appointment as Certified Workers' Compensation Mediator Initial Application Renewal Please complete this form, sign under penalty of perjury and return with a current resume to the: Court of Existing Claims, Attention: Counselor Department, 1915 N. Stiles Avenue, Ste 127, Oklahoma City, OK 73105-4918. NOTE: Failure to provide all requested information may delay consideration of your application. ALL INFORMATION SUBMITTED TO THE COURT MAY BE CONSIDERED A PUBLIC RECORD UNDER STATE LAW. Direct all questions regarding disclosures to the Counselor Department. Attorney Name: Office Address (Street Address): Mailing Address: Profession/Occupation Firm Name: City City Cities In Which Available State State Zip Code Zip Code OBA Number Office Phone Fax Number E-Mail Address Yes 1. 2. 3. Are you an active or senior member in good standing of the Oklahoma Bar Association for at least three (3) years immediately preceding the date of this application? Are you knowledgeable of Oklahoma workers' compensation principles and the Oklahoma workers' compensation system? Describe your training and/or experience as a mediator: Attach an extra sheet if necessary. Describe your training and/or experience evidencing knowledge of workers' compensation principles and the Oklahoma workers' compensation system: Attach an extra sheet if necessary. Have you, within the twelve (12) months immediately preceding this application: (a) completed six (6) hours of mediation training approved by the Oklahoma Bar Association MCLE Commission or sponsored by the Court of Existing Claims, and (b) observed or mediated at least two (2) workers' compensation mediation proceedings? No 4. 5. NOTE: If you answer YES to question(s) 6 and/or 7, please provide an explanation of each on a separate sheet and attach to this application. 6. 7. Have you been the subject of any disciplinary proceedings in any state for misconduct as lawyer that resulted in disbarment, suspension, public censure, private reprimand, or revocation of your license to practice law? Have you been convicted within the past ten (10) years of a felony or of a crime involving dishonesty or false statement? I hereby request appointment to the Court of Existing Claims's list of certified workers' compensation mediators, and certify that I meet the minimum requirements for certification as a workers' compensation mediator pursuant to the Court's rules. If appointed I agree to complete mediation within thirty (30) days following contact by the parties for scheduling arrangements. I agree to conduct up to two (2) pro bono mediations annually if requested by the Court of Existing Claims. I agree to submit biennially to the Court Administrator written verification of compliance with the continuing education requirements of Rule 52(D)(2) of the Court of Existing Claims. I agree to accept as payment in full an amount not to exceed the maximum rate or fee set forth in Court Administrator Rule 4 for services rendered as a certified workers' compensation mediator. I agree to comply with all applicable statutes and the rules of the Court of Existing Claims and the Court Administrator. I agree to comply with all applicable standards of impartiality and confidentiality. I hereby authorize any and all associations, organizations and State and Federal agencies to release to the Court of Existing Claims upon request, any and all documents and information necessary and relevant to the investigation and approval of this application. I declare under penalty of perjury that the statements contained herein are true and correct to the best of my knowledge and belief. I understand that false or misleading information may result in rejection of my application or, if previously appointed, in removal from the list of certified workers' compensation mediators. Signature Rev. 06/24/2014 Date American LegalNet, Inc. www.FormsWorkFlow.com