Page 1 of 4 UJS-380 MEDIATOR APPLICATION Rev. 06/2015 MEDIATOR APPLICATION FORM UNIFIED JUDICIAL SYSTEM OF SOUTH DAKOTA CIRCUIT COURT Name: Name of Business Organization: Address: Day Time Phone: E-mail Address: Instructions: Please complete the following questionnaire as specified under each section. If additional space is needed, attach a sheet for each area making sure to indicate the section of the questionnaire to which you are responding. This form must be filed with the Presiding Judge for each circuit in which you intend to participate in court appointed mediation. 1) Provide your professional background including degree(s), certificate(s), practice specialization(s), years of experience and special training: American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 4 UJS-380 MEDIATOR APPLICATION Rev. 06/2015 2) Provide a full and complete disclosure of all professional employment experiences whether in the field of mediation or in any other field: 3) Provide complete information regarding any training, seminars, workshops, etc., you deem pertinent to mediation: 4) Provide the number of mediations in which you have been involved giving approximate dates of those mediations if available. Please indicate how many of the mediations were successful. American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 4 UJS-380 MEDIATOR APPLICATION Rev. 06/2015 5) Describe methods of mediation you have used and time required to conduct a typical mediation: 6) Please describe how fees and costs are calculated for completion of a typical mediation: American LegalNet, Inc. www.FormsWorkFlow.com Page 4 of 4 UJS-380 MEDIATOR APPLICATION Rev. 06/2015 7) Please describe the requirements for payment of fees: I am aware of and agree to abide by the principles and guidelines set out in South Dakota Codified Law and as promulgated by the Supreme Court of South Dakota. Signature of Applicant Date NOTE: This form must be updated as changes to the information occur or at least annually. Approved: Signature of Presiding Judge Date American LegalNet, Inc. www.FormsWorkFlow.com