UNITED STATE S DISTRICT COURT EASTERN DISTRICT OF TENNESSEE FEDERAL MEDI ATION P ROGRAM APPL ICAT ION TO BECOME AN AP PROVED ME DIATORNAME: __________________________________________________________BPR NO.: _________________________________FIRM NAME: (IF APPLICABLE ) OFFICE ADDRESS: ___________________________________ ___________________________________ ___________________________________OFFICE PHONE: ___________________________________ IN ORDER TO BE APPROVED A S A MEDI ATOR IN THIS COURT, YOUMUST MEET THE FOL LOWING QUALIFI CATIONS AND ALSO AGREE T O BEBOUND BY THE FOLLO WING: 1. All mediators must be lawyers, licensed to practice in the State of Tennessee and admitted to practice in the United States District Court for the Eastern District of Tennessee; 2. All mediators shall have practiced law at least five years; 3. All mediators shall have had formal procedural and substantive training, including at least forty (40) hours of formal mediation training as approved by the Court. Procedural training shall be provided by the Clerk of the Court. 4. Mediators must report the results of their mediations in accordance with Local Rule 16.4(m). 5. Mediators shall agree that they will be available to conduct at least one pro bono mediation per year. >>>> 2 6. Mediators shall commit to at least one year of service on the Mediation Panel. 7. Mediators shall agree to participate in any reporting and research requirements of the program. 8. All mediators shall agree to comply with the provisions of the program as set forth in Local Rule 16.4, EDTN (copy attached). 9. All mediators shall agree to provide the Court with biographical information that the Court may require that will be made available to litigants and lawyers who are seeking mediators. YOUR APPL ICATION WILL BE REVIEWE D BY THE COURTSSTA NDING COMM ITTEE ON APPROVAL AND EVA LU AT ION OF MEDIATORS. MEMBERS OF THIS COMMI TTEE ARE MAGI STRAT E JUDGE SHIRLEY,MAGISTRATE J UDGE INMAN AND SHELBY GRUBBS, ESQ. YOU WILL BENOTIFIED BY A COMMIT TEE ME MBER OF ACTION TAKEN ON YOURAPPLI CATION. IF YOU ARE APPROVED, PROCEDURAL TRAINING WI LL BEPROVIDED BY THE CLERK OF THE COURT.DATE ADMITTED TO PRACTICE BEFORE THE TENNESSEE SUPREME COURT:___________________DATE ADMITTED TO PRACTICE BEFORE THE UNITED STATES DISTRICT COURT FOR THEEASTERN DISTRICT OF TENNESSEE:________________________________________________________NUMBER OF YEARS OF LAW PRACTICE (this can include time spent clerking for a federal or state judge): ___________________________The following training requirements must be met: Additional substantive training shall not be required for mediators who can show that they have received at least forty (40) hours of mediation training approved by the Tennessee Commission on Continuing Legal Education and Specialization, the American Arbitration Association, Dispute Management, Inc., Mediation and Conflict Management Services of St. Louis, United States Arbitration & Mediation or equivalent training as determined by the Standing Committee on Approval and Evaluation of Mediators.>>>> 3Please set forth the training you have received which qualifies you for the FederalMediation Program: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ___________ ____________________________________________________________ I HEREBY CER TIFY, UNDER PENAL TY OF PERJUR Y, THAT THE INFORMA TION STA TED HERE IN BY ME IS TRU E AND CORR ECT. I MEET ALL THE REQUI REMENTS TO BECOME A FE DERAL COURT MEDIAT OR AND I HEREBY AGRE E TO COMPLY WIT H THE PROVISIONS OF THE PROGRAM A S SET FORTH ABOVE. ___________________________________ SIGNATUREDATE:_____________________________ Return the completed form to: Honorable C. Clifford Shirley, Jr. United States Magistrate Judge Howard H. Baker Jr. U. S. Courthouse 800 Market Street, Suite 144 Knoxville, TN 37902