UNITED STATES DISTRICT COURT WESTERN DISTRICT OF TEXAS SAN ANTONIO DIVISION Mediator Application 1 Name: __________________________________________________________________________________________ Address: _________________________________________________________________________________________ City: _____________________________________ State: ________ Zip: ___________________ E-Mail: __________________________________________ 1. Telephone: _______________ Fax: ______________ Are you a member of the Bar of the Western District of Texas? ______ Yes ______ No Date of admission: ___________________________________ 2. Please list states in which you are admitted to practice and dates of admission, and State Bar ID Number: State _____________ Date of Admission: ________________ State Bar ID No.: ____________________ State _____________ Date of Admission: ________________ State Bar ID No.: ____________________ State _____________ Date of Admission: ________________ State Bar ID No.: ____________________ 3. Please describe any training you have taken in mediation or in other forms of ADR. Please include the dates of the training, the sponsor and whether the training qualified for Texas MCLE credit. Type of Training _______________________ _______________________ _______________________ Dates ___________ ___________ ___________ No./Hrs. ___________ ___________ ___________ Sponsor _______________________ _______________________ _______________________ Yes ________ No MCLE Credit ___________ ___________ ___________ _______ 4. 5. Have you ever been a judge of a court of record in Texas? Please check all applicable areas of substantive experience: _____ Bankruptcy _____ Civil Rights _____ Contracts _____ Corporate _____ Insurance _____ Intellectual Property _____ Personal Injury _____ Securities _____ Real Property _____ Constitutional _____ Environmental _____ Labor/Employment Other (please describe) ______________________________________________________________________ "I understand that my completed application may be made available by the Clerk of Court to litigants or counsel seeking information about my experience. I further understand that I may be asked to provide mediation services pro bono, no more than once a year." ___________________________________________________ Applicant's Signature __________________________ Date To be eligible for inclusion on the list of ADR providers maintained by the Court, an individual must (1) be a member of the Western District of Texas bar, (2) be a member of a state bar for at least five years, and (3) have completed an approved 40-hour dispute resolution training program or served as a judge in Texas. American LegalNet, Inc. www.FormsWorkFlow.com 1