APPLICATION FOR CERTIFICATION AS AN ARBITRATOR LOCAL CIVIL RULE 53.2 U.S. DISTRICT COURT - EASTERN DISTRICT OF PENNSYLVANIA (1) Name: Office: Address: Office Phone: (2) Date admitted to practice before: Pennsylvania Supreme Court United States District Court 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 orde r, 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) >>>> 2 (8) Please list the name(s) of a judge, or judges, of this Court before whom you have app ear ed or who otherwise may have knowledge of your qualifications. (9) If you have not na med any ju dge of this Court in answer to question No. 8, please list any other federal judges or state judges before whom you have appeared or who may otherwise have knowledge of your qualifications. (10) Have you ever been publicly disciplined by a ny Court or Administrative Office of a Court. If "Yes," give details. Yes No (11) Have you ever been convicted of a felony? Yes No If "Yes," give details. (12) Please set forth any additional information you believe would bear upon your qualifications to serve as an arbitrator. >>>> 3(13) Do you understand the compensation limitations for arbitrators appointed under Local Civil Rule 53.2 and do you agree to accept as full compensation payments within those limits? YES NO (14) In the event you are certified as an arbitrator, would you be willing on occasion to serve on "short notice" in situations where, for some reason, the arbitrator originally appointed is not available? YES NO I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT DATE: (Signature) (Rev 10/02)