United States Distr ict Cour t Distr ict of Or egon Application to Ser ve as a Cour t-sponsor ed Mediator Local Rule 16-4 permits the Court to refer a case to mediation with a mediator whose name appears on the District s list of Court-sponsored mediators. Court-sponsored mediators agree to conduct mediation for four hours per case without cost to the parties. If the parties do not settle the case within the four hours, the mediator and the parties may discuss whether to continue mediation and, if agreed, how much the mediator will be paid per hour. Payment arrangements are to be made between the mediator and the parties. Court-sponsored mediators agree to perform at least eight hours of mediation service for the Court per calendar year without payment. NAME Last First Middle Initial FIRM Bar No. (specify the state) ADDRESS Office Phone No. Cell Phone No. FAX No. WEBSITE JUDICIAL EXPERIENCE E-mail Address YES NO If Yes, insert name of the Court(s): PRACTICE EMPHASIZES PRIMARILY: PLAINTIFF DEFENSE BOTH MEDIATION TRAINING (Please attach proof of training. Mediators must have at least 30 hours of mediation training to qualify. See LR 16-4(j)(4).): MEDIATION EXPERIENCE (Mediators must have at least 12 hours of actual mediation experience to qualify. See LR 16-4(j)(4)): LISTING OF THE GEOGRAPHICAL AREAS OR LOCATIONS IN THE DISTRICT OF OREGON WHERE WILLING TO SERVE (complete all applicable): Cities: Counties: Entire State (check box if applicable): I have read Local Rule 16-4. 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 of any district, circuit, or appellate court in the United States. Dated: Signature U.S. Dist r ict C ou r t O r egon Revised February 17, 2011 Ap p lica t ion t o Ser ve a s a C ou r t -sp on sor ed M ed ia t or Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com SURVEY OF SUBJ ECT MATTER EXPERTISE Conflict resolution requires communication and mediation skills that help parties identify issues and interests, identify areas of common ground, allow parties to be heard, and envision creative solutions. However, lawyers sometimes also wish to know a mediator s specific areas of expertise. Please think carefully about your personal level of expertise in the following general subject areas. (Note: These categories are those displayed on the civil cover sheet submitted to the court at the time of case initiation.) Designate with a 1 those main categories (like CONTRACT, REAL PROPERTY, etc.) that are your primary subject areas of expertise. Designate with a 2 those categories in which you have some experience. Designate with a 3 those categories in which you have little or no experience. Place an X next to any category of case, or speciality within a category, for which you would not wish to serve as a mediator. ______CONTRACT _____ 110 Insurance _____ 120 Marine _____ 130 Miller Act _____ 140 Negotiable Instrument _____ 150 Recovery of Overpayment & Enforcement of Judgment _____ 151 Medicare Act _____ 152 Recovery of Defaulted Student Loans (Excl. Veterans) _____ 153 Recovery of Overpayment of Veteran s Benefits _____ 160 Stockholders Suits _____ 190 Other Contract _____ 195 Contract Product Liability _____ 196 Franchise ______REAL PROPERTY _____ 210 Land Condemnation _____ 220 Foreclosure _____ 230 Rent Lease & Ejectment _____ 240 Torts to Land _____ 245 Tort Product Liability _____ 290 All Other Real Property ______TORTS (Personal Injury) _____ 310 Airplane _____ 315 Airplane Product Liability _____ 320 Assault, Libel & Slander _____ 330 Federal Employers Liability _____ 340 Marine _____ 345 Marine Product Liability _____ 350 Motor Vehicle _____ 355 Motor Vehicle Product Liability _____ 360 Other Personal Injury _____ 362 Personal Injury - Medical Malpractice _____ 365 Personal Injury - Product Liability _____ 368 Asbestos Personal Injury Product Liability (Personal Property) _____ 370 Other Fraud _____ 371 Truth in Lending _____ 380 Other Personal Property Damage _____ 385 Property Damage Product Liability ______CIVIL RIGHTS _____ 441 Voting _____ 442 Employment _____ 443 Housing/Accommodations _____ 444 Welfare _____ 445 Amer. w/ Disabilities-Employment _____ 446 Amer. w/ Disabilities-Other _____ 440 Other Civil Rights ______BANKRUPTCY _____ 422 Appeal 28 USC 158 _____ 423 Withdrawal 28 USC 157 ______PRISONER PETITIONS _____ 510 Motions to Vacate Sentence _____ 530 General _____ 535 Death Penalty _____ 540 Mandamus & Other _____ 550 Civil Rights _____ 555 Prison Condition ______FORFEITURE/PENALTY _____ 610 Agriculture _____ 620 Other Food & Drug _____ 625 Drug Related Seizure of Property, 21 USC 881 _____ 630 Liquor Laws _____ 640 R.R. & Truck _____ 650 Airline Regs. _____ 660 Occupational Safety/Health _____ 690 Other ______LABOR _____ 710 Fair Labor Standards Act _____ 720 Labor/Mgmt. Relations _____ 730 Labor/Mgmt. Reporting & Disclosure Act _____ 740 Railway Labor Act _____ 790 Other Labor Litigation _____ 791 Empl. Ret. Inc. Security Act ______PROPERTY RIGHTS _____ 820 Copyrights _____ 830 Patent _____ 840 Trademark ______SOCIAL SECURITY _____ 861 HIA (1395ff) _____ 862 Black Lung (923) _____ 863 DIWC/DIWW (405(g)) _____ 864 SSID Title XVI _____ 865 RSI (405(g)) ______FEDERAL TAX SUITS _____ 870 Taxes (U.S. Plaintiff or Defendant) _____ 871 Taxes IRS - Third Party 26 USC 7609 ______OTHER STATUTES ____ 400 State Reapportionment _____ 410 Antitrust _____ 430 Banks and Banking _____ 450 Commerce/ICC Rates/etc. _____ 460 Deportation _____ 470 Racketeer Influenced & Corrupt Org. _____ 480 Consumer Credit _____ 490 Cable/Sat TV _____ 810 Selective Service _____ 850 Securities/Commodities/Exchange _____ 875 Customer Challenge 12 USC 3410 _____ 890 Other Statutory Actions _____ 891 Agricultural Acts _____ 892 Economic Stabilization Act _____ 893 Environmental Matters _____ 894 Energy Allocation Act _____ 895 Freedom of Information Act _____ 950 Constitutionality of State Statutes SUBMIT U.S. Distr ict Cour t Or egon Revised February 17, 2011 Application to Ser ve as a Cour t-sponsor ed Mediator Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com