FORM ADR - 1003 July 2018 1 OFFICE OF THE EXECUTIVE SECRETARY OF THE SUPREME COURT OF VIR GINIA APPLICATION FOR MEDIATOR RECERTIFICATION Please use black ink and type or print so document will be legible when scanned. This application will be considered pursuant to certification criteria established by the Judicial Council of Virginia and without regard to race, color, political affiliation, national origin, disability, sex or age. SECTION I GENERAL INFORMATION 1. Name: Last First Middle Business Name (if different from above): Mailin g Address: Street and/or Post Office Box City State Zip Code County 2. Phones/Home : Work : Fax: 3. E - Mail: Website: 4. Certification Number: Please check any item you do NOT want posted in the online Searchable Mediator Directory. Business Name Street Address City County Zip Code Home Phone Work Phone Fax Email Website If you prefer to post alternate contact information online for any of the above, please list that information below. 5. Recertifications r equested: General District Court Circu it Court - Civil J & DR District Court Circuit Court - Family American LegalNet, Inc. www.FormsWorkFlow.com FORM ADR - 1003 July 2018 2 SECTION II C ONTINU ING EDUCATION Requirements for one or multiple certification levels: 10 hours of approved continuing mediation education (CME) , includ ing a minimum of 2 hours mediator ethics (8 CME hours + 2 Ethics = 10 Total Hours) A: CME Carry Over Hours from Previous Recertification Number of CME hours carried over from the previous recertification cycle ( m ax 8) B : Current Cycle Continui ng Mediator Education If you have more than 10 CMEs, you may submit evidence of completing up to an additional 8 hours to carry over for your next recertification period. This continuing education must have occurred since your original certification (if this is your first R ecertification) or since your last recertification date . ATTACH ALL CME EVIDENCE . Please note the number of each type of CME earned: CME Amount Type Non - ethics trainings approved by DRS (max 16) Mediator ethics trainings approved by DRS (minimum 2, max 18) Mediator Peer Consultation ( m ax 6) Self - Reflective Co - mediation hours ( m ax 3) Trainer CME for delivering CME courses or CLE seminars related to mediation ( m ax 6) Total ( minimum 10, m ax 18) C : CME Carryover for Next Recertification CME carried over ( A ) CME Earned ( B ) 10 for Recert CME carryover for next recertification ( m ax 8) SECTION III BACKGROUND 1. Have you ever 1) had a disciplinary action related to a profession, including mediation (for ex ample, 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. + - = NOT APPLICABLE 2018 - 1 9 N/A 2018 - 19 American LegalNet, Inc. www.FormsWorkFlow.com FORM ADR - 1003 July 2018 3 2. Have you ever been convicted of a felony, a misdemeanor (includes reckless and aggressive driving), a includes guilty or nolo contendere pleas. Yes No If Yes, list on the lines provided below ( please include the specific code section(s) violated ) . 3. Please describe the impact, if any, that such conviction(s) could have on your ability to provide mediation services. SECTION IV EVALUATION AND CERTIFICATION I understand that in court - referred cases, I will provide an initial orientation session for the parties, and their lawyers if they choose to attend, at no cost to the parties. I understand that I am obligated as a condition of my continuing certification: (1) to familiarize myself with, and abide by, the Standards of Ethics a nd Professional Responsibility for Certified Mediators , adopted by t he Judicial Council of Virginia effective July 1, 2011; and (2) to e nsure that Forms ADR - 1002 (Evaluation of Mediation Session(s) and Mediator(s)) are provided to all parties referred from the courts. I understand that to carry over excess CME to my next recertification period, I must report it on this form and attach evi dence. I also hereby certify that the information provided in this application is true to the best of my knowledge and accurately reflects my qualifications to provide mediation services in cases referred through the court system of the Commonwealth of V irginia. I understand that all information here in is subject to verification. Signature of Applicant Date 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 Or email it to d rsapplications @vacourts.gov If you have any questions or comments, please contact Dispute Resolution Services, 804 - 786 - 6455. American LegalNet, Inc. www.FormsWorkFlow.com FORM ADR - 1003 July 2018 4 Important Information Regarding the Recertification Process 1. Recertification is required every 2 years on November 1. Note t he first recertification date may be less than 2 years after initial certification, depending on the certification date. 2. An applicant for recertification must complete and submit FORM ADR - 1003 and evidence of CME that falls between the last recertification date and October 31 st of the year currently due for recertification. 3. DRS recommends mediators keep detailed records of carryover credits. DRS will keep a record of carryover hours for each mediator . D may result in application delays. 4. Applicants for recertification may request approval by DRS for education relevant to mediation practice they receive from organizations such as the Association for Conflict Resolution, the American Bar Association Section on Dispute Resolution, appropriate courses sponsored by Virginia Continuing Legal Education, and others to meet the requirements for continuing education. When requesting approval, the applicant should submit an outline or agenda describing the content of the educational program. 5. Mediators participating in an approved MPC may receive up to 6 hours of CME credit for attendance at such sessions. 6. Mediators who complete a SRC may receive up to 3 hours of CME credit for 3 hours of co - mediation followed by self - reflection. To receive credit, the mediator will need to attach FORM ADR - 1012 . 7. Mediators who provide advanced mediation skill s training or present an advanced CL E seminar related to the subject of mediation may receive up to 6 hours of CME credit. Evidence of providing such training, information on the length of the training, the number of times the training was offered during the recertification period , and the number of hours spent in preparation for the course must be provided. 8. Notification of recertification shall be made through letter and certificate. A letter denying recertification shall state the grounds for the deni al and reference the right to request reconsideration by the Executive Secretary of the Supreme Court of Virginia within 30 calendar days of the recertification denial notification date . The written request must be received by the Executive Sec retary within 5 calendar days after expiration of the 30 day time period. The reconsideration request must include the reasons recertification is warranted. 9. A mediator denied recertification may reapply for initial certification after 6 months from the d ate of the final denial. In the sole discretion of DRS, partial waivers of training and mentorship requirements may be granted on a case - by case basis. 10. Mediators who do not meet the recertification requirements may not hold themselves out as certified me diators, may not mediate court - referred cases without a certified co - mediator, may not mentor others seeking certification, and may not train others seeking certification. 11. A mediator whose certification lapsed after not meeting the recertification require ments in a timely manner must reapply for initial certification. In the sole discretion of DRS, deviations from the initial certification requirements may be allowed or required on a case - by - case basis. 12. If a core course trainer has not been certified as a mediator for over 2 years, and