IN THE UNITED STATES BANKRUPTCY COURT FOR THE WESTERN DISTRICT OF PENNSYLVANIA APPLICATION FOR ADMISSION TO BANKRUPTCY MEDIATION PROGRAM REGISTER General Instructions (1) Each applicant shall read Local Bankruptcy Rules 9019-2 through 9019-7. (2) If additional space is needed to respond fully to any item on this application, the response(s) shall be set forth in an attached, signed separate page with an identification of the question number to which it responds. (3) (4) Attorney applicants shall complete Parts I, II and IV of this Application. Non-attorney applicants shall complete Parts I, III and IV of this Application. Part I. ALL APPLICANTS. Name: ______________________________________________________________________________ Firm: _______________________________________________________________________________ Office Address: _______________________________________________________________________ Street ____________________________________________________________________________________ City State Zip Code Office Phone: _________________________________________________________________________ Office Fax: ___________________________________________________________________________ E-Mail: _____________________________________________________________________________ Pa. I.D. or other Professional Association I.D. _________________________________________________ PAWB Local Form 31 (07/13) Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Part II. ATTORNEY APPLICANTS 1. List each state and federal court in which you currently are licensed to practice law: Court Date of Admission ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 2. If you have bankruptcy experience, list the three most recent adversary proceedings or contested matters in which you have served as attorney of record for a party-in-interest from commencement through conclusion (i.e., judgment, order, or stipulation). Case Title a. Case Number Dates Representation ______________________________________________________________________________ ____________________________________________________________________________________ ______________________________________________________________________________ ____________________________________________________________________________________ b. ______________________________________________________________________________ ____________________________________________________________________________________ c. 3. If you have bankruptcy experience, list the most recent three bankruptcy cases in which you have served as the principal attorney of record (without regard to the party represented) from commencement to conclusion. Case Title a. Case Number Dates Representation ______________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ______________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ b. ______________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ c. PAWB Local Form 31 (07/13) Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com 4. If you have participated in mediation or other ADR processes (either as a neutral or in another role), list the three most recent of those matters below. Case Title a. Case Number Dates Representation ______________________________________________________________________________ ____________________________________________________________________________________ ______________________________________________________________________________ ____________________________________________________________________________________ b. ______________________________________________________________________________ ____________________________________________________________________________________ c. Part III. NON-ATTORNEY APPLICANTS 1. If you have participated in mediation or other ADR processes (either as a neutral or in another role), list no more than three of those matters below. Case Title Case Number Dates Representation a. ______________________________________________________________________________ ____________________________________________________________________________________ ______________________________________________________________________________ ____________________________________________________________________________________ b. ______________________________________________________________________________ ____________________________________________________________________________________ c. Part IV. ALL APPLICANTS 1. List any professional licenses you hold (other than bar admission) and include the number of years you have practiced in each profession listed (e.g., accountant, real estate broker, appraiser, engineer). Profession Accrediting Organization Years of Practice ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ PAWB Local Form 31 (07/13) Page 3 of 5 American LegalNet, Inc. www.FormsWorkFlow.com 2. List any professional organizations of which you are or were an active member, the length of your membership, and any positions held and/or projects completed. Organization No. of Years Active/Retired Positions/Projects _______________