APPLIC AT ION FOR APPROVA L A S A MEDIA TOR UNDER LOCAL CIVIL RULE 53.3 U.S. DISTR IC T COURT - EAST ER N DISTR ICT OF PENNSYLV ANIA (1) Name: Office: Address: Office Phone: (2) Date Admitted to Practice before: Pennsylvania Supreme Court: United States District Court for the Eastern District of Pennsylvania: (3) Date admitted to practice before the highest Court of a State (other than Pennsylvania) or the District of Columbia. Court: Date of Admission: (4) Set forth briefly in chronological order, with dates, the nature of your practice of law since admission to the bar. (5) Are you presently engaged in the active practice of law in the Eastern District of Pennsylvania? Yes: No: (6) State briefly the nature of your present practice: (7) Which of the following best describes your present practice of law? (Check one).(a) My practice primarily consists of representing defendants: (b) My practice primarily consists of representing plaintiffs: (c) My practice cannot be designated as either (a) or (b): 1 >>>> 2(8) Do you specialize in any particular area(s) of law? Yes: No: If yes, state the area(s) of expertise and the time during which you have specialized in that area of law. (9) Have you had any training as a mediator or other neutral? Yes: No: If yes, briefly set forth the details of such training with dates of training. (10) Are you willing to provide training for mediators and other neutrals? Yes: No: If yes, set forth the details of your experience in training mediators and other neutrals with dates of such training. (11) Please list the name(s) of a judge, or judges, of this Court before whom you have appeared or who otherwise may have knowledge of your qualifications. (12) If you have not named any judge of this Court in answer to question No. 11, please list any other federal judges or state judges of courts of record before whom you have appeared or who may otherwise have knowledge of your qualifications. (13) Have you ever been publicly disciplined by any Court or Administrative Office of a Court? Yes: No: If "Yes," give details. NOTE: You have a continuing obligation to notify the Court of any public discipline by any Court or Administrative Office of a Court after submission of this Application and after such time as you may be certified as a neutral. 2>>>> 3(14) Have you ever been convicted of a crime? Yes: No: If "Yes," give details. (15) If approved as a mediator under Local Civil Rule 53.3, I agree to serve in a pro bono capacity without compensation. Yes: No: I HEREB Y CERTIF Y THAT THE ABOVE INFORMAT ION IS TRUE AND CORRE CT .DATE: (Signature)