For Office Use (this box only) APPLICATION FEE PAYMENT: LABEL TENNESSEE SUPREME COURT ALTERNATIVE DISPUTE RESOLUTION COMMISSION APPLICATION FOR LISTING AS RULE 31 MEDIATOR NOTE: An applicant shall not advertise or proclaim in any manner that he/she is listed as a Rule 31 mediator until approved by formal action of the Tennessee Supreme Court Alternative Dispute Resolution Commission. INSTRUCTIONS AND AUTHORIZATION / RELEASE: Check at least one of the following two boxes (or both if applicable), on page 1 below, and complete all attorney and/or other license(s) information therein. Sign and date on the line at the end of the box, or both boxes, that you check. Note: If licensure is not applicable to you at all, you still need to check the second box and sign and date on the line at the end of the second box. ‘ ATTORNEY LICENSE(S): If I hold, or have ever held, a license to practice law, I have listed below the license number(s) for the license(s), and for non-Tennessee license(s) the licensing or disciplinary agency(ies), and I hereby authorize and request the Tennessee Supreme Court Board of Professional Responsibility (BPR), and/or the attorney licensing or disciplinary agency of any other state, to provide to the Tennessee Supreme Court Alternative Dispute Resolution Commission (ADRC) information regarding the status of my license(s) and all disciplinary complaints ever filed against me, including, but not limited to, those administratively dismissed by the BPR or any other agency and those resulting in non-public discipline. Tennessee Attorney License / BPR #: Year Licensed: If licensed to practice law in other state(s), complete the following for each license: State Year Licensed Name of Disciplinary Agency Address/Phone I.D.# DATE: SIGNATURE: ‘ OTHER PROFESSIONAL LICENSE(S): If I hold, or have ever held, a professional license other than that of an attorney, I have listed below the license number(s) and the licensing or disciplinary agency(ies) for the license(s), and I hereby authorize such agency(ies) to provide to the Tennessee Supreme Court Alternative Dispute Resolution Commission (ADRC) information regarding the status of my license(s) and all disciplinary complaints ever filed against me, including, but not limited to, those administratively dismissed by such agency(ies) and those resulting in non-public discipline. Tennessee Professional License #(s): Year Licensed (for each): List name, address, and phone number of the licensing agency for each Tennessee license: If professionally licensed in other state(s), complete the following for each license: State Year Licensed Name of Disciplinary Agency Address/Phone I.D.# DATE: SIGNATURE: Page 1 of 6 American LegalNet, Inc. www.USCourtForms.com Please type or print . PART I 1. If you need more space to complete this form, please enclose separate sheet(s) of paper indicating the question(s) to which you are responding. GENERAL INFORMATION Name: Last First Middle Title (Ms. / Mr. / Dr.) 2. For my address on correspondence and lists of approved Rule 31 mediators, please use (check one): ‘ business address ‘ home address. (If no preference indicated, your business address will be used.) 3. Current Business Address (include name of business if desired): City 4. County Zip Code County State Zip Code Current Home Address: City 5. State Preferred base county for your Rule 31 mediator listing (usually one of the counties indicated in # 3 or # 4 above): ; (or, if # 3 and # 4 are out of state, choose a preferred Tennessee base county): 6. Telephone: ( 7. Email Address: 8. Social Security No.: . PART II ) Fax: ( - - ) Date of Birth: / / BACKGROUND INFORMATION EDUCATION: 1. What is the highest degree that you have attained to date? Note: 2. If not a licensed attorney: Must enclose with application either: a copy of your transcript, or a copy of your diploma, for highest degree attained. Colleges and Universities attended: Name of School City/State Dates Attended (from-to) Page 2 of 6 Degree(s) Attained Major American LegalNet, Inc. www.USCourtForms.com OCCUPATION: 3. What is your primary occupation? ‘ Attorney ‘ Certified Public Accountant ‘ Counselor ‘ Government Employee (Government Agency/Title: ‘ Other (please specify): ‘ ‘ ‘ ‘ Mediator Physician Professor Psychiatrist ‘ ‘ ‘ ‘ Psychologist Retired Judge Social Worker Teacher ) 4. List work history to date (or enclose resume), to establish number of years and type of work experience: 5. List professional affiliations that you consider relevant to your application: 6. List volunteer work that you think pertinent to this application, as well as other relevant life experience: OTHER BACKGROUND: 7. Have you ever been convicted of any violation(s) of the law? Exclude traffic violations unless they resulted in the revocation or suspension of your license. ‘ No ‘ Yes (If yes, please explain): 8. Have you ever been subjected to discipline by any professional organization? ‘ No ‘ Yes (If yes, please explain): 9. Have your professional privileges been curtailed at any time? ‘ No ‘ Yes (If yes, please explain): Note: The failure of an applicant to acknowledge that she or he has been (1) convicted of a violation of the law other than a traffic violation not involving suspension of a driver=s license; (2) disciplined by a professional organization or had his/her professional privileges curtailed; or (3) that criminal or professional disciplinary proceedings are pending; may result in denial of listing or subsequent removal of neutral from listing. Page 3 of 6 American LegalNet, Inc. www.USCourtForms.com PART III 1. MEDIATION AND TRAINING I am applying for listing as a (check one or both): ‘ ‘ General Civil Mediator Family Mediator ‘ 2. If applying for Family Mediator Listing: I have completed an ADRC-approved domestic violence course of at least 12 hours, and wish to be listed as specially trained in domestic violence. I have enclosed proof of course attendance. 3. List the county or counties in which you are willing to serve as a mediator: 4. IF APPLYING FOR GENERAL CIVIL MEDIATION, COMPLETE THE FOLLOWING: Rule 31 mediators in general civil cases – must “[c]omplete forty hours of general mediation training which includes the curriculum components specified by the Alternative Dispute Resolution Commission (ADRC) for Rule 31 mediators in general civil cases;” – OR, if 46 hours of ADRC approved family mediation training have been completed, must complete 16 hours of ADRC approved family to civil cross-over training. (A.) I have completed 40 hours of Rule 31 ADRC-approved general civil mediation training; OR, after completing 46 hours of ADRC approved family mediation training, I have completed 16 hours of ADRC approved family to civil cross-over training: ‘ Yes ‘ No The training course(s) I completed are listed below; and I have enclosed a copy of my certificate of completion or other proof of completion for each course listed: # Hours Course Name Location Date(s) Trainer/Organization OR: (B.) I am applying to be listed as a mediator under Section 17(d)(i) of Rule 31. I have completed at least three semester hours of general mediation training at an accredited law school, as listed below, in a program or programs substantially equivalent to that required under Rule 31 as determined by the ADRC; I have four years of practical work experience; and I have enclosed a course outline provided by the law school professor, and a copy of my certificate of completion or other proof of completion, for each course listed: # Hours Course Name Location Page 4 of 6 Date(s) Trainer/Organization American LegalNet, Inc. www.USCourtForms.com OR: (C.) I am applying to be listed as a mediator under Section 17(d)(ii) of Rule 31. I have completed at least 40 hours of general mediation training, as listed below, in a program or programs substantially equivalent to that required under Rule 31 as determined by the ADRC, within ten years prior to my submittal of this application; and I have enclosed a course outline provided by the trainer, and a copy of my certificate of completion or other proof of completion, for each course listed: # Hours 5. Course Name Location Date(s) Trainer/Organization IF APPLYING FOR FAMILY MEDIATION, COMPLETE THE FOLLOWING: Rule 31 mediators in family cases – must “[c]omplete forty hours of training in family mediation which includes the curriculum components specified by the Alternative Dispute Resolution Commission (ADRC) for Rule 31 mediators in family cases and which also includes four hours of training in screening for and dealing with domestic violence in the mediation context,” and “complete six additional hours of training in Tennessee family law and court procedure;” – OR, if 40 hours of ADRC approved civil mediation training have been completed, must complete EITHER: 24 hours of ADRC approved civil to family cross-over training plus 6 additional hours of training in Tennessee family law and court procedure, or 30 hours of ADRC approved civil to family cross-over training. (A.) I have completed 46 hours of Rule 31 ADRC-approved family mediation training including 6 hours of training in Tennessee family law; OR, after completing 40 hours of ADRC approved civil mediation training, I have completed either: 24 hours of ADRC approved civil to family cross-over training plus 6 hours of training in Tennessee family law, or 30 hours of ADRC approved civil to family cross-over training: ‘ Yes ‘ No The training course(s) I completed are listed below; and I have enclosed a copy of my certificate of completion or other proof of completion for each course listed: # Hours Course Name Location Date(s) Trainer/Organization OR: (B.) I am applying to be listed as a mediator under Section 17(d)(i) of Rule 31. I have completed at least three semester hours of family mediation training at an accredited law school and six additional hours of training in Tennessee family law and court procedure, as listed below, in programs substantially equivalent to that required under Rule 31 as determined by the ADRC; I have four years of practical work experience; and I have enclosed a course outline provided by the law school professor, and a copy of my certificate of completion or other proof of completion, for each course listed: # Hours Course Name Location Page 5 of 6 Date(s) Trainer/Organization American LegalNet, Inc. www.USCourtForms.com OR: (C.) I am applying to be listed as a mediator under Section 17(d)(ii) of Rule 31. I have completed at least 40 hours of family mediation training and six additional hours of training in Tennessee family law and court procedure, as listed below, in a program or programs substantially equivalent to that required under Rule 31 as determined by the ADRC, within ten years prior to my submittal of this application; and I have enclosed a course outline provided by the trainer, and a copy of my certificate of completion or other proof of completion, for each course listed: # Hours PART IV Course Name Location Date(s) Trainer/Organization REFERENCES List the name, address, phone number, and occupation of two professional references other than relatives: 1. 2. PART V SIGNATURE I certify that the information supplied on this application is correct, to the best of my knowledge, and that I qualify for the category(ies) of listing(s) for which I have applied. I will notify the Alternative Dispute Resolution Commission of any address changes. I understand that all information herein is subject to verification. I have read Tennessee Supreme Court Rule 31 regarding alternative dispute resolution. If this application is accepted, I agree to comply with the policies and regulations set forth in that Rule and all subsequent amendments. I agree to notify the Alternative Dispute Resolution Commission promptly should any professional license I hold be revoked, or should I be disciplined by the Board of Professional Responsibility or any applicable agency. I agree to submit to the jurisdiction of the courts of Tennessee and the Alternative Dispute Resolution Commission for purposes of fulfilling my obligation to comply with Rule 31 as it may be amended in the future. Signature of Applicant Date Send application and check for $100.00* application fee to: Tennessee Supreme Court Alternative Dispute Resolution Commission Nashville City Center, Suite 600 511 Union Street Nashville, TN 37219 Make check payable to: Alternative Dispute Resolution Commission. Upon receipt of your complete application, you will be mailed a postcard indicating the date your application will be reviewed. *Note: According to ADRC policy, application fee is $200.00 IF: You are applying based on training requirement waiver, as stated in Rule 31 Section 17(d)(ii) and as referenced on pages 5 and 6 of this application under Part III (4)(C) and/or (5)(C). Page 6 of 6 American LegalNet, Inc. www.USCourtForms.com