AGREEMENT TO SERVE AS MEDIATOR IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF OREGON _____ _____ NEW AGREEMENT UPDATED AGREEMENT NAME: ____________________________________________________________ Last First Middle Initial ADDRESS: __________________________ __________________________ __________________________ BAR NO. PHONE NO. FAX NO. E-MAIL __________________ __________________ __________________ __________________ LAW FIRM, PARTNERS OR ASSOCIATES: ______________________________ ________________________________________________________________________ ________________________________________________________________________ PRINCIPAL AREAS OF PRACTICE (please identify if predominantly plaintiff or defense): ____________________________________________________________ ________________________________________________________________________ OTHER FIELDS OF TRAINING/EXPERIENCE: ______________________________ ________________________________________________________________________ LEGAL AND NONLEGAL ORGANIZATIONS WITH WHOM YOU ARE AFFILIATED: ______________________________________________________ ________________________________________________________________________ MEDIATION TRAINING EXPERIENCE: ____________________________________ ________________________________________________________________________ DIVISIONS WILLING TO SERVE IN (check as many as apply): _____ _____ _____ Portland Eugene Medford I have read Local Rule 16.4 and I am willing to serve as a volunteer mediator, and thereby agree to perform at least eight hours of volunteer mediation service per calendar year without payment. I am a member in good standing of the Oregon State Bar and I have been admitted to practice in the United States District Court for the District of Oregon for at least five years, and/or I am a retired or senior judge. _____________________________________ Signature __________________ Date American LegalNet, Inc. www.FormsWorkflow.com AFTER COMPLETING THE UPPER PORTION OF THIS FORM, PLEASE COMPLETE THE CASE PREFERENCE AND SELF-EVALUATION. CASE PREFERENCE AND SELF-EVALUATION Please mark each case category in the appropriate place to indicate your expertise in the area and/or your interest in arbitrating that type of case. “Major Experience” means that this is or has been a major emphasis of your practice. “Some Experience” means that you are familiar with the basic principles of law and have had some experience in that area. “Little or No Experience” means that you have little or no experience in the area, but that you are still interested in hearing such case. “Don’t Want” means that you would prefer not to be appointed to this type of case for any reason. Categories of Cases Major Exper. Some Exper. Little/ No Exper. Don’t Want 1. CONTRACT/BUSINESS/GENERAL a. Government Contracts b. Insurance Contracts _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ 2. REAL PROPERTY - GENERAL a. Condemnation _____ _____ _____ _____ _____ _____ _____ _____ 3. PERSONAL INJURY - GENERAL a. Airplane b. Defamation c. FELA d. Maritime e. Product Liability f. Medical Malpractice g. Asbestos _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ 4. CIVIL RIGHTS - GENERAL _____ _____ _____ _____ 5. LABOR/EMPLOYMENT - GENERAL _____ a. Traditional Labor Law _____ b. Wrongful Discharge _____ c. ERISA - Pension _____ d. Wage Claims _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ 6. INTELLECTUAL PROPERTY GENERAL a. Patent b. Trademark c. Copyright _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ OTHER a. Admiralty b. Environmental c. Antitrust _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ 7. American LegalNet, Inc. www.FormsWorkflow.com d. e. f. g. Banking RICO Securities Other (Specify) _____________ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ ______ American LegalNet, Inc. www.FormsWorkflow.com