Form 292 COUNTY REFERRAL LIST INFORMATION SHEET COUNTY: Name: Address: Phone: FAX: E-Mail: Alternative Dispute Resolution Service(s) Provided: (Check Applicable boxes) Mediation Arbitration Early Neutral Evaluation Other (please describe) Education/Training/Certification: Experience (please describe): Hours Available: Fees Charged: I hereby agree to accept at least two referrals per year in actions in t his county in which the clerkhas found that a party is entitled to proceed in forma pauperis pursuant to Rule 3.I hereby agree to submit on an annual basis the information specified on this form. Name (printed) Signature DateIn order to be placed on a county referral list, please return to the Su perior Court Clerk in that County. 9/03 SML