CIRCUIT COURT OF THE STATE OF OREGON Fourth Judicial District Court-Connected Mediator Application Form Qualifications for mediators are based upon the Oregon Judicial Department Court-Connected Mediator Qualifications Rules, issued as Chief Justice Order (CJO) No. 05-028, effective August 1, 2005. For more information regarding the CJO go to: http://www.ojd.state.or.us/web/OJDPublications.nsf/Files/05cER001sh.pdf/$File/05cER001sh.pdf Guidelines for Mediator Applicants can be found at: http://courts.oregon.gov/Multnomah/docs/civilcourt/mediation_guidelinesformediatorapplicants.pdf Instructions for submitting the completed form are at the bottom of the last page of this form. . Please note: Approved applications will appear on the court website as public information. General Information Applicant's Last Name: First Name, Middle Initial: Title: Mailing Address: Business Phone (1): Business Phone (2): Fax: E-Mail (1): E-Mail (2): Website: I Am Applying To Be A: General Civil Mediator Probate Mediator Domestic Relations Custody and Parenting Mediator Domestic Relations Financial Mediator Yes Yes Yes Yes No No No No I adhere to the following organization's code(s) of professional ethics (e.g. OMA, OSB, ACR, AAA, etc.): I certify that I include in my opening remarks to the parties the required information specified in Section 1.4(3) of the CJO. (Initials) P a g e | 1 of 7 Mediator Application Form American LegalNet, Inc. www.FormsWorkFlow.com Current Employment Information Professional Memberships It is required that you attach diplomas, certificates, or other forms of verification for the sections of the application below that contain an asterisk. * Basic Mediation Training (verifying certificates or diplomas required) Basic Mediation Training (Minimum required: 30 hours) [Sections 2.1(1)(a), 2.2(2)(a), 2.3(2)(a), & 3.2] Indicate the description, trainer(s), number of hours, and dates. If you have not had Basic Mediation Training, describe substantially similar training or education. (Please note that experience as a mediator does not constitute "training.") * Court System Training (verifying certificates or diplomas required) Describe your court system training. (Minimum required: 8 hours) [Sections 2.1(1)(b), 2.2(2)(c), 2.3(2)(d), & 3.5] Indicate the description, trainers(s), number of hours, and dates. If you have not had 8 hours of Court System Training, describe substantially similar training or education. Indicate the trainer(s), number of hours, and dates. Mediation Experience (Only General Civil Mediator and Probate Mediator applicants complete the next two boxes.) Describe your observations of 3 actual mediations [in accordance with Section 2.1(2)]. P a g e | 2 of 7 Mediator Application Form American LegalNet, Inc. www.FormsWorkFlow.com Describe your experience mediating or co-mediating where you were observed by a qualified supervisor in 3 court-connected civil cases [in accordance with Section 2.1(2)] . Probate Mediators (Only Probate Mediator applicants complete the next box.) I am applying to be a probate mediator (conservatorship/guardianship, estate disputes, and/or trust matters). I meet the qualifications set forth in SLR 12.045(8). Please describe how you qualify: (e.g. attorney with five years relevant experience; individual with special skills and training in administration of estates, trusts or protective proceedings; or mediator training) I have completed the Multnomah County Probate Department mediation training. _______ Initials _________________ Date of Training (Both Domestic Relations Custody and Parenting Mediator and Domestic Relations Financial Mediator applicants complete the next 3 boxes.) Domestic Relations Mediators *Education (verifying certificates or diplomas required) Enter your Law, Master's, or Doctorate degree in a specific field. [Sections 2.2(1)(a-c) & 2.3(1)] Include the institution's name, dates attended, and degrees awarded. If you have none of the above, but have a bachelor's degree and 7 years of relevant experience, enter your degree, the institution's name, dates attended, and degrees and date awarded. Then describe your 7 years of relevant experience. [Sections 2.2(1)(d) & 2.3(1)] P a g e | 3 of 7 Mediator Application Form American LegalNet, Inc. www.FormsWorkFlow.com *Domestic Relations Custody and Parenting Mediator Training (verifying certificates or diplomas required) (Minimum required: 40 hours.) [Sections 2.2(2)(b), 2.3(2)(b) & 3.3] Indicate the description, trainer(s), number of hours, and dates. (Only Domestic Relations Custody and Parenting Mediator applicants complete this box.) (Please describe your participation in at least 20 domestic relations cases, with 100 hours supervised or co-mediated with qualified supervisor; minimum 10 cases/50 hours custody and parenting mediation; or at least 2 years full-time experience as described in Section 2.2(3). Include name(s) or supervisor(s) and/or co-mediator(s). Domestic Relations Custody and Parenting Mediator Experience. (Only Domestic Relations Financial Mediator applicants complete the next 3 boxes.) (verifying certificates or diplomas required) (Minimum: 40 hours domestic relations financial issues training) [Sections 2.3(2)(2) & 3.4] Indicate the description, trainer(s), number of hours, and dates. * Domestic Relations Financial Mediator Training P a g e | 4 of 7 Mediator Application Form American LegalNet, Inc. www.FormsWorkFlow.com (Please describe your participation in at least 20 domestic relations cases, with 100 hours supervised or co-mediated with qualified supervisor; minimum 10 cases/50 hours domestic relations financial mediation; or at least 2 years full-time experience as described in Section 2.3(3). Include name(s) or supervisor(s) and/or co-mediator(s). Domestic Relations Financial Mediator Experience. I certify that I have in effect, and shall maintain during my court-connected mediator listing, malpractice insurance or self-insurance with comparable coverage as required by Section 2.3(7). Insurance for Domestic Relations Financial Mediators Insurance Company Initials Other Mediation Training (All applicants complete the next 3 boxes.) Enter description(s) of specialized or advanced mediation training. Other Experience Describe any other relevant experience. Describe any special skills or experience you have (e.g. second language proficiency, cultural sophistication, non-mediation related licenses or skills, other relevant education, etc.). P a g e | 5 of