OFFICE OF THE EXECUTIVE SECRETARY SUPREME COURT OF VIRGINIA APPLICATION FOR MEDIATION COURSE CERTIFICATION CONTINUING MEDIATOR EDUCATION (CME) Applications for CME certification must be submitted at least thirty (30) days in advance of the training date. DRS will review applications within thirty (30) calendar days of receipt. Please note that extra time should be allotted beyond the thirty (30) days for the applicant to make any changes/revisions that may be necessary. This application will be considered pursuant to certification criteria established by the Judicial Council of Virginia and without regard to race, color, religion, political affiliation, national origin, disability, sex or age. SECTION I TRAINER INFORMATION (Please type or print.) 1. Name(s) and address(es) of trainer(s): Telephone: Fax: 2. Certified Virginia Mediator? Yes Is your certification current? Yes No No Email: Certification #: 3. Are you currently a Certified Trainer through our office? Yes No If not, please attach a resume to this application that includes your experience as a trainer of adult audiences. 4. Please attach a description of your qualifications for presenting this particular topic. 5. What types of training assistants are required to aid you in delivering this training? Panelists, subject matter experts, speaker, demonstrator, role-play observer (must be appropriately certified), special group facilitators, etc. Or none? SECTION II COURSE INFORMATION 1. Title of proposed course: 2. Length of training: Family Ethics 3. Type and # of CME hours requested: General FORM ADR-2001 January 2015 1 American LegalNet, Inc. www.FormsWorkFlow.com 4. If your course is less than two hours, check here. Please attach a course outline or summary that describes the content and the course evaluation form that will be used. 5. If your course is two hours or more, check here. Attach the following: a. a detailed training agenda with exact times to be spent on each subject specified b. the course outline c. course materials including any handouts, exercises, manuals, role-plays, etc. d. the course evaluation form that will be used e. a description of the training format such as lecture, discussion, small group exercises, visual aids, role-plays, demonstration, panel, etc. SECTION III 1. BACKGROUND Have you ever been convicted of a felony, a misdemeanor (includes reckless and aggressive driving), a traffic violation resulting in suspension or revocation of a driver's license, or a DUI/DWI? Conviction includes guilty or nolo contendere pleas. Yes No If Yes, list on the lines provided below (please include the specific code section(s) violated). 2. Have you ever 1) had a disciplinary action related to a profession, including mediation (for example, a professional license suspended or revoked); 2) had any professional privileges curtailed; and/or 3) relinquished a professional privilege or license while under investigation? Yes No If Yes, describe on the lines provided below. 3. If you answered "Yes" to question #1 or #2 above, please describe the impact, if any, this could have on your ability to provide mediation services. SECTION IV CERTIFICATION I understand that information regarding this course may be provided to individuals seeking training by the Office of the Executive Secretary. I hereby certify that the information provided in this application is true to the best of my knowledge. I understand that all information herein is subject to verification and that the training may be observed at any time by a representative of the Office of the Executive Secretary as a part of the certification process. Signature of Trainer Date 2 FORM ADR-2001 January 2015 American LegalNet, Inc. www.FormsWorkFlow.com Please forward this application to: Dispute Resolution Services Office of the Executive Secretary Supreme Court of Virginia 100 N. Ninth Street, Third Floor Richmond, VA 23219-2308 If you have any questions or comments, please contact Dispute Resolution Services at 804-786-6455. FORM ADR-2001 January 2015 3 American LegalNet, Inc. www.FormsWorkFlow.com