UNITED STATES DISTRICT COURT DISTRICT OF SOUTH CAROLINA Application for Mediators Please complete the entire application, using additional paper if necessary. You may also attach a resume. Name: _______________________________________________________________________________________ Firm or Office Name: ___________________________________________________________________________ Office Address: ____________________________________________________________________________________________ Office Phone: _____________________________ Office Fax: ________________________________________ E-mail Address: _______________________________________________________________________________ ADMISSIONS AND AFFILIATIONS Date admitted to the Bar of the District of South Carolina: ______________________ Date admitted to the South Carolina Bar: ____________________________________ 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? _______ yes _______no I.D. No.: _____________ Bar No.: ______________ Have you, within the last five years, been publicly reprimanded or publicly disciplined for professional conduct? _______yes _______no Have you, within the last five years, been denied admission to a bar for character or ethical reasons, or been disbarred/suspended from the practice of law? _______ yes _______no EDUCATION Year law degree received __________ Law School ________________________________________ Other professional degrees received (including year and school): LEGAL EXPERIENCE (A minimum of five years of law practice required) Summarize legal experience (including teaching) since admission to the bar, particularly in the past five years: American LegalNet, Inc. www.FormsWorkFlow.com Percentage of practice in last 5 years representing plaintiff % or defense % State % % Percentage of Federal or State court practice in last 5 years: Federal Number of years engaged in active litigation: SUBSTANTIVE EXPERIENCE Indicate all substantive areas in which you have experience. Place a "1" by your strongest area(s) and a "2" by all other areas in which you have experience. (Do not rank beyond "1" and "2.") After any category you have marked, please identify any sub-areas of experience you have (e.g. "medical malpractice" after Personal Injury). Admiralty Antitrust Contracts Environment Fraud or Civil RICO Insurance Miller Act Personal Injury Product Liability Other (specify) Publications: Security or Shareholders suits Labor ERISA Wrongful Termination Civil Rights in Employment Other Civil Rights Copyrights Patent Trademark MEDIATION EXPERIENCE Mediation experience (particularly in the subject matter categories above): Other courts or organizations for whom you serve as a mediator (please note any certifications): ______________ Number of mediations conducted: MEDIATION AND OTHER ADR TRAINING Course Provider Course Content Number of other ADR sessions conducted: ______________ Date Place No. of Hours American LegalNet, Inc. www.FormsWorkFlow.com OTHER INFORMATION Are you familiar with the statutes, rules and practice governing alternative dispute resolution in the District of South Carolina? yes no Other relevant experience or skills or other information you would like considered in connection with this application: Cities in which you are available to conduct mediation: Columbia Other Charleston Greenville Florence Fees charged: Hourly Rate: $ How do you bill for travel? (explain): Minimum charge each mediation:$ I agree to: (1) Be subject to the Rules of Professional Conduct, Rule 407, South Carolina Appellate Court Rules; the Rules for Lawyer Disciplinary Enforcement, Rule 413, South Carolina Appellate Court Rules; and the Local Rules of the District Court; (2) Provide mediation to indigents without pay if ordered by the Court; (3) Notify the Alternative Dispute Resolution Program Director of any change in the above facts or otherwise in my ability to perform duties as a mediator; (4) Disclosure of information contained in this application to litigants and other members of the public. I certify that the foregoing is true and correct. Date: Applicant Return completed application to: Danny H. Mullis, Director Alternative Dispute Resolution Program United States District Court Post Office Box 835 Charleston, SC 29402-0835 Reviewed: _________________________________ ADR Program Date: ________________ ________________ Signature: 2/2016 Approved: ___________________________________ U.S. District Judge Date: _____________ American LegalNet, Inc. www.FormsWorkFlow.com