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