Tennessee Supreme Court Alternative Dispute Resolution Commission Rule 31 Listed Mediator RENEWAL APPLICATION FORM – 2008 Complete all applicable information. Type of Mediator (please check): Name: General Civil and Family* Mediator General Civil Mediator Family* Mediator *Family Listing has “Specially Trained in Domestic Violence Issues” designation Approval Date of Civil Listing: General Civil Approval Date of Family Listing: Family ( Note: Must notify ADRC of address change within 30 days of change) Current Information: Name: Address: City/State/Zip: Base County: Phone: Fax: Email: Occupation: 1. List below the Continuing Mediation Education (CME) and/or Continuing Legal Education (CLE) courses you have taken to meet the Continuing Education requirements of Rule 31 Section 18(a). (If more space is needed, please use reverse side.) Title Date # of Hours # of Hours # of Hours # of Hours Mediation Mediation Ethics General TN Family Law Continuing Education Continuing Education Continuing Education Continuing Education Policy regarding CLE/CME requirements to remain listed as a Rule 31 mediator: General Civil Listing = 6 hours every 2 years, including at least 3 hours of mediation education of which at least 1 hour shall be mediation ethics. Family Listing = 6 hours every 2 years, including at least 3 hours of mediation education of which at least 1 hour shall be mediation ethics, and 3 hours of TN family law. Note: CLE and other professional continuing education hours may meet the requirements of Rule 31. 2008 Renewal Form, p. 1 of 3 American LegalNet, Inc. www.FormsWorkflow.com 2. List below the county(ies) in which you are willing to serve as a Rule 31 mediator. (Note: List will include at least one county, your base county, plus any other county(ies) you wish to specify.) Or, if preferred, please specify below your base county plus the “statewide” category. (Note: If listed under the “statewide” category, individual counties other than your base county will not be specified unless explicitly requested.) 3. IF NOT ALREADY designated, do you wish to be listed as a mediator specially trained in domestic violence issues? (See T.C.A. §36-6-107, T.C.A. §36-6-409, and T.C.A. §36-6-305.) NOTE: You must be already listed as a Family mediator, AND you must have completed the ADRC-approved 12-hour course on domestic violence mediation . If applicable, please attach your Training Certificate from the required approved course. Yes No 4. List below any pro bono mediations you have conducted since you last renewed (or, if new mediator, since you became listed). (If more space is needed, please use reverse side.) Type of Case 5. Mediation Hours Do you have any professional license(s)? Yes No License #: Name, Address, and Phone of licensing agency: Preparation and Follow-Up Hours Court Ordered? Yes/No If yes, provide the following for each license: Year Licensed: (a.) Have your professional privileges been curtailed at any time? * Yes No If yes, please explain (include date of curtailment and current status of professional privileges): (b.) Do you have any pending disciplinary actions against you now? * Yes No * Note: The failure of a Rule 31 listed mediator to acknowledge that she or he has been disciplined by a professional organization or that his or her professional privileges have been curtailed, may result in denial of the mediator’s renewal application or in the subsequent removal of the mediator from listing. 6. Please sign and date your renewal application below: I certify that the information supplied on this renewal application form is correct to the best of my knowledge and that I qualify for the renewal of my Rule 31 mediator listing(s). I will notify the Alternative Dispute Resolution Commission (ADRC) promptly of any change in my address or contact information. 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 Rev. 8-08 2008 Renewal Form, p. 2 of 3 American LegalNet, Inc. www.FormsWorkflow.com pursuant to Supreme Court Rule 31 Section 18(f)(2) to provide notification of such action to the ADRC within 14 days of receipt of being advised of such revocation or suspension by the professional licensing agency or organization. I understand that all information herein is subject to verification. I have read Tennessee Supreme Court Rule 31 regarding alternative dispute resolution and the related ADRC Policies found at www.tsc.state.tn.us/geninfo/Publications/ADR/ADRPolicies.pdf. I agree to comply with the policies and regulations set forth in that Rule and all subsequent amendments. I agree to submit to the jurisdiction of the courts of the state 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 Date Enclose $100.00 Renewal Fee and Return to: Tennessee Supreme Court Alternative Dispute Resolution Commission Attn: Anne-Louise Wirthlin 511 Union Street, Suite 600 Nashville, TN 37219 Make check payable to: Alternative Dispute Resolution Commission Rev. 8-08 2008 Renewal Form, p. 3 of 3 American LegalNet, Inc. www.FormsWorkflow.com