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Appplication For Inclusion On Courts Register Of Qualified Mediators Form. This is a Oregon form and can be use in Bankruptcy Court Federal.
Tags: Appplication For Inclusion On Courts Register Of Qualified Mediators, 201, Oregon Federal, Bankruptcy Court
UNITED STATES BANKRUPTCY COURT DISTRICT OF OREGON In re APPLICATION FOR INCLUSION ON COURT'S REGISTER OF QUALIFIED MEDIATORS ) ) ) ) ) I, ______________________________________________________, the undersigned, hereby apply for inclusion on the Register of Mediators Qualified for Service in the United States Bankruptcy Court for the District of Oregon. In making this application I certify under penalty of perjury that all of the following information is true and correct: 1. I will fully comply with the relevant provisions of this court's General Orders, Local Rules, and Local Forms, and any modifications thereto, relating to mediation. 2. I have been licensed under the laws of Oregon in the professions listed below (e.g., attorney, accountant, real estate broker, appraiser, engineer, etc.) for the number of years indicated: Profession Accrediting Organization Years 3. I am, or have been, a member in good standing of the following professional organizations: Organization Membership # Number of Years Active/Retired 4. A general explanation of my experience in each of my aforementioned professions is listed below: 5. I have completed the following Oregon State Bar Continuing Education mediation training programs: Hours Course 201 (4/5/10) CLE Credits Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 6. The following is a list of other court, state or federal mediation programs I have completed: Court Program Hours 7. The following is a general statement concerning other pertinent mediation training I have received: 8. The following is a brief explanation of my pertinent bankruptcy experience: 9. The following is a general explanation of any other pertinent experience I have: 201 (4/5/10) Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 10. I have: (a) never been suspended, disbarred or had any professional license revoked; (b) no pending proceeding to suspend or revoke any of my professional licenses; and (c) never been convicted of a felony. 11. The following is a list of each of my previous applications for inclusion on any court's Mediation Register, and an explanation of the current status of each such application (e.g., present status; circumstances, and date, of any removal): Application Date Court Present Status 12. Unless fully disclosed and the potential disqualifying circumstance was then waived by the court and all parties, 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; and I knew of no other reason that would disqualify me as a mediator. 13. I will immediately contact the court, and any parties for whom I have accepted appointment as a mediator, upon learning I am no longer qualified to serve pursuant to the provisions of LBR 9019-2, or this Application (e.g., due to an adverse change of circumstances relating to points 10 or 12). Dated: _________ ____________________________________________________________ Signature ____________________________________________________________ Print or Type Name of Signer ____________________________________________________________ Address ____________________________________________________________ ____________________________________________________________ Telephone Number ____________________________________________________________ E-mail 201 (4/5/10) Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com