UNITED STATES DISTRICT COURT WESTERN DISTRICT OF TEXAS AUSTIN DIVISION APPLICATION TO BECOME APPROVED MEDIATOR NAME: FIRM OR ORGANIZATION: STREET ADDRESS: CITY, STATE, ZIP: TELEPHONE: EMAIL ADDRESS: 1. Are you a member of the Bar of the Western District of Texas? Date of admission: 2. State Bar ID No.: FAX: Are you a faculty member of an accredited Texas law school? Name of school: 3. Please list states/courts in which you are admitted to practice and dates of admission: 4. Have you ever been subject to any disciplinary action, sanction, contempt order, or reprimand by any court, Bar, or judicial administration body? If yes, provide details on separate sheet. 5. Please describe any formal training you have received in mediation or other forms of Alternative Dispute Resolution. Please include the dates of the training, the sponsor, and whether the training qualified for Texas MCLE credit. Attach additional sheets if necessary. Type of Training Dates No./Hrs. Sponsor MCLE Credit TXWD- AUS - Mediator Application (Rev. 12/2015) American LegalNet, Inc. www.FormsWorkFlow.com 6. Please describe the extent and nature of your experience as a mediator, including approval/certification by other jurisdictions or agencies. 7. Please check all applicable areas of substantive experience: 9 Bankruptcy 9 Environmental 9 Real Property 9 Civil Rights 9 Insurance 9 Securities 9Constitutional 9 Intellectual Property 9 Contracts 9 Administrative 9 Corporate 9 Personal Injury Other (describe): Please submit this application, a current resume or curriculum vitae, and a certificate of good standing from the Supreme Court of Texas to: Annette French, Division Manager United States District Court, Western District of Texas Austin Division 501 West Fifth Street Austin, Texas 78701 "I hereby affirm that the information provided above is true and correct. I understand that my completed application may be made available by the Clerk of Court to litigants or counsel seeking information about my experience." Applicant Signature: Date: TXWD- AUS - Mediator Application (Rev. 12/2015) American LegalNet, Inc. www.FormsWorkFlow.com