Application For Mentor Status Form. This is a Virginia form and can be use in Supreme Court Statewide.
Tags: Application For Mentor Status, ADR-4000, Virginia Statewide, Supreme Court
For DRS Use Only Approved _______ Date ___________ OFFICE OF THE EXECUTIVE SECRETARY SUPREME COURT OF VIRGINIA (Effective January 1, 2007) ______________________________________________________________________________ APPLICATION FOR MENTOR STATUS Please use black ink so this document will be legible when scanned. SECTION I. 1. GENERAL INFORMATION Name: ____________________________________________________________________ Last First Middle Business Name (if different from above): ________________________________________ Primary Address: _______________________________________ _________________ Telephone __________________________________________________________________________ City State Zip Code County 2. E-mail Address: ____________________________________________________________ 3. Certification Number: ________ 4. Court Level(s) for which Mentor Status is Requested: 5. Most Recent Recertification Date: _________________________ SECTION II. Court Level(s): GDC GDC JDR JDR CCC CCC CCF CCF CERTIFIED TRAINING 1. Were you approved as a Mentor prior to January 1, 2007? Yes ____ No _____ If yes, proceed to question #3. 2. Please list the mediation training you have received and dates beyond those courses you have taken to receive certification. (Add additional sheets if needed.): Training 3. Date Have you attended an OES certified 4-hour course related to “Mentoring Individuals Seeking Certification as a Court-Referred Mediator”? Yes ____ No _____ FORM ADR-4000 January 2009 Page 1 American LegalNet, Inc. www.FormsWorkflow.com 4. 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. Provide 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.) 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. I understand that all information herein is subject to verification. ___________________________________________________ Signature of Applicant FORM ADR-4000 January 2009 _______________________ Date Page 2 American LegalNet, Inc. www.FormsWorkflow.com