UNITED STATES DISTRICT COURT DISTRICT OF RHODE ISLAND ADR PANEL APPLICATION Please complete the entire application, using additional paper if necessary. You may also attach a resume, however, you must complete and return this application. Name:______________________________________________________________________. Firm or Office Name:__________________________________________________________. Office Address:_______________________________________________________________. Phone:________________________. Fax:___________________________. E-mail______________________________. ADMISSIONS AND AFFILIATIONS Date admitted to the Federal Bar, District of Rhode Island: Date admitted to the Rhode Island Bar: Bar No.: Other courts or jurisdictions to which admitted (with dates of admission and bar nos.): Membership and positions held in bar, ADR and professional associations: Are you a member in good standing in each jurisdiction where admitted to practice law? __No Yes Are you currently the subject of any pending disciplinary proceeding in any jurisdiction? No Yes Have you ever been denied admission to a bar for character or ethical reasons or disciplined for professional misconduct? Yes No EDUCATION: Year law degree received . Law School: . Other professional degrees received (including year and school)_________________________. Other education_________________________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com LEGAL EXPERIENCE(A minimum of 10 years of law practice required): Summarize legal experience since admission to the bar: Percentage of practice in last 5 years representing plaintiff % or defense Percentage of federal or state court practice in last 5 years: Federal Number of years engaged in active litigation: % % State % . EXPERTISE: Indicate all substantive areas in which you have legal or other expertise: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ PUBLICATIONS: ADR TRAINING & EXPERIENCE Describe your experience and training in ADR. Also, indicate any ADR certifications you hold, when they were awarded and by whom. Page 2 of 3 American LegalNet, Inc. www.FormsWorkflow.com Other courts or organizations for whom you serve as an ADR panel member or neutral mediator: OTHER INFORMATION Please describe any other information, knowledge or skills you wish to be considered as part of this application. CERTIFICATION: I am making application to serve on the ADR Panel for District of Rhode Island and certify that the foregoing is true and correct. Signature Date Return completed application to: Berry B. Mitchell Office of Alternative Dispute Resolution United States District Court 1 Exchange Terrace Providence, RI 02903 Form: ADR Panel Application (April 10, 2008) Page 3 of 3 American LegalNet, Inc. www.FormsWorkflow.com