OFFICE OF THE EXECUTIVE SECRETARY SUPREME COURT OF VIRGINIA (Effective July 1, 2011) ______________________________________________________________________________ APPLICATION FOR MENTOR STATUS Please use black ink so this document will be legible when scanned. SECTION I. 1. Name: GENERAL INFORMATION Last First Middle Business Name (if different from above): Primary Address: City State Zip Code Telephone: County 2. 3. 4. 5. E-mail Address: Certification Number: Court Level(s): GDC GDC JDR JDR CCC CCC CCF CCF Court Level(s) for which Mentor Status is Requested: Most Recent Recertification Date: CERTIFIED TRAINING SECTION II. 1. 2. Were you approved as a Mentor prior to January 1, 2007? If yes, proceed to question #3. Yes No Have you attended an OES certified 4-hour course related to "Mentoring Individuals Seeking Certification as a Court-Referred Mediator"? Yes No 3. If yes, list date and location of training: Please attach either the original or a photocopy of your course completion certificate. SECTION III. MEDIATION EXPERIENCE 1. Year you became certified as a court-referred mediator: 2. Attach evidence of having completed 10 cases and 30 hours of mediation at the court level(s) for which Mentor status is sought. (If approved as a Mentor prior to January 1, 2007, proceed to Section IV.) FORM ADR-4000 July 2011 1 American LegalNet, Inc. www.FormsWorkFlow.com SECTION IV. 1. MENTOR RESPONSIBILITIES What is your understanding of the obligations and responsibilities of a Mentor in preparing and evaluating a mentee? (Add additional sheets if needed.) I hereby certify that the information provided in this application is true to the best of my knowledge and accurately reflects my qualifications to provide mentorship services in cases referred through the court system of the Commonwealth of Virginia. My signature on any OES mentorship form(s) certifies that I have personally mentored and evaluated the applicant seeking court-referred mediator certification. If approved for Mentor status, I agree to adhere to the Standards of Ethics and Professional Responsibility for Mediators, adopted by the Judicial Council of Virginia effective July 1, 2011. I understand that all information herein is subject to verification. Signature of Applicant Date Please forward this application to: Dispute Resolution Services Office of the Executive Secretary 100 N. Ninth Street, Third Floor Richmond, VA 23219 If you have any questions or comments, please contact Dispute Resolution Services, 804-786-6455. FORM ADR-4000 July 2011 American LegalNet, Inc. www.FormsWorkFlow.com Supreme Court of Virginia 2