Solano — Adr panelist application website 9 22 2014 address modifications

Source: https://solano.courts.ca.gov/system/files/adr-panelist-application-website-9-22-2014-address-modifications.pdf

Form 3904

SUPERIOR COURT OF CALIFORNIA COUNTY of SOLANO Dispute Resolution Panelist Application

Please submit completed application to: ADR Administrator Superior Court of California, County of Solano 580 Texas Street Fairfield, CA 94533 Email:ADR@solano.courts.ca.gov Fax: (707) 425-4996 I. CONTACT INFORMATION Name: Firm/Company/Home: (circle one) Mailing Address: City: State: Zip: E-mail: Phone: Cell: Fax: Emergency Contact: Phone:

II. MARK THE PANELS FOR WHICH YOU ARE APPLYING Mediator Neutral Evaluator* Arbitrator** Small Claims Mediator (*Must be licensed attorney with 10 years significant experience or a retired judge.) (**Must be licensed attorney with 5 years experience or a retired judge.)

III. PANELS Only complete the panel sections for which you are applying.

MEDIATOR
A. MEDIATION TRAINING:
I have completed a continuous, 40-hour course within the past two (2) years.
I have completed a continuous, 40-hour course more than two (2) years ago, and
within the past two (2) years I have completed at least seven (7) hours of continuing or
advanced mediation training.
Other (please specify):
(List only 40-hour advanced or specialized mediation courses.)
You may add up to one additional page if necessary.)

Course Title Instructor (name) Hours Date

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B. MEDIATION EXPERIENCE: List current affiliations with all dispute resolution providers,
including the Superior Court of California, County of Solano, other courts, governmental
entities and indicate if you are in private mediation practice: (Add up to one additional page if
necessary.)

Mediate for: Court/Entity/Private # of cases Years

C. FEE SCHEDULE: List all fees and expenses that you charge for mediation services. Hourly fee: $ Daily fee: $ Minimum number of hours: Administrative fee: $ Cancellation fee: $ Travel fees: $ Other fees, charges or policies:

D. ACKNOWLEDGMENT: If approved as a mediator, I agree to take the Superior Court of California, County of Solano’s two (2) hour Mediation Program Orientation course, and meet its continuing education requirement of ten (10) hours every three (3) years, including one hour of ethics. I agree to follow the Superior Court of California, County of Solano’s Ethical and Practice Standards for ADR Panel Members. I agree that I have mediated at least six (6) civil cases within the last two years that were at least two hours in length.

NEUTRAL EVALUATOR

A. NEUTRAL EVALUATION EXPERIENCE: List up to three (3) areas of primary practice focus in which you have had at least ten (10) years of significant legal experience: Please list any specialization for which you are certified:

(List trial experience: types of cases tried to verdict or judgment, approximate number of cases, years of practice.) (Add up to one additional page if necessary.)

Types of Cases (broad categories) # of Cases Years

B. ACKNOWLEDGMENT: If approved as a Neutral Evaluator, I agree to take the Superior Court of California, County of Solano’s two (2) hour Helpful Early Neutral Case Evaluation, HENCE, Program Orientation, and meet its continuing education requirement of ten (10) hours every 3 years. I agree to follow the Superior Court of California, County of Solano’s Ethical and Practice Standards for ADR Panel Members.

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C. FEE SCHEDULE: List all fees and expenses that you charge for neutral evaluation services. Hourly fee: $ Daily fee: $ Minimum number of hours: Administrative fee: $ Cancellation fee: $ Travel fees: $ Other fees, charges or policies:

ARBITRATOR

A. ARBITRATION TRAINING: (You may add up to one additional page if necessary.)

Course Title Instructor (name) Hours Date

B. ARBITRATION EXPERIENCE: (List arbitration experience, including solo arbitration and panels on which you have served, predominant types of cases and approximate number of cases.)

Court/Organization Types of Case Arbitrated # of Cases

C. FEE SCHEDULE: List all fees and expenses that you charge for arbitration services. Hourly fee: $ Daily fee: $ Minimum number of hours: Administrative fee: $ Cancellation fee: $ Travel fees: $ Other fees, charges or policies:

D. ACKNOWLEDGMENT: If approved as a an Arbitrator, I agree to take the Superior Court of California, County of Solano’s two (2) hour Arbitration Program Orientation course, and meet its continuing education requirement of 10 hours every three years. I agree to follow the Superior Court of California, County of Solano’s Ethical and Practice Standards for ADR Panel Members.

SMALL CLAIMS MEDIATOR

A. MEDIATION TRAINING: I completed at least 25-hours of a continuous course that meets DRPA standards. (You may add up to one additional page if necessary.)

Course Title Instructor (name) Hours Date

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B. MEDIATION EXPERIENCE: (If no mediation experience, please leave blank.)
Court # of Cases Mediated Years

I have conducted Small Claims Appeals mediations.

C. ACKNOWLEDGMENT:
If approved as a Small Claims Mediator, I agree to take the Superior Court of California,
County of Solano’s two (2) hour Small Claims Mediation Program Orientation course, and
meet its continuing education requirement of ten (10) hours every three years.
I agree to follow the Superior Court of California, County of Solano’s Ethical and Practice
Standards for ADR Panel Members.

IV. AREAS OF EXPERTISE (To be completed by all applicants. Check only areas of actual experience.) Banking Environment Partnership Business/Contracts Family Law Personal Injury Civil Harassment* Custody Probate/Trust Administration Consumer C Divorce Professional Malpractice Conservatorship/ Foreclosure Public Entity Guardianship Health Care/Insurance Real Estate Construction/Defect Homeowner Association Securities Education Intellectual Property Small Claims Eminent Domain Landlord/Tenant Unlawful Detainer* Employment/Labor Medical Malpractice Other * (To mediate Civil Harassment or Unlawful Detainer each has a two-hour update course requirement.) V. BACKGROUND INFORMATION (Indicate all categories that apply to you.) Retired judge Member of the California State Bar: Bar #: Date Admitted: Status: Active Inactive Currently Practicing Represent: Plaintiff: % Defendant: % Other: specify: (Contractor, CPA, Therapist, etc#: VI. EDUCATION (Indicate all levels that apply to you.) High School Diploma GED AA Degree BA/BS Degree Masters Degree Doctorate Juris Doctorate Other (specify) VII. OTHER INFORMATION 1. Languages, other than English, in which you are proficient enough to conduct a session:

2. Are you in good standing in each state in which you are licensed?
Not Applicable Yes No (If “No”, please attach separate sheet with explanation.)
3. Have you ever been convicted of a felony?
No Yes (If “Yes,” please attach separate sheet with explanation.)

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4. Has there been any entry of judgment against you in any civil action for actual fraud or
punitive damages?
No Yes (If “Yes,” please attach separate sheet explanation.)
5. Have you ever been convicted of a misdemeanor involving theft or moral turpitude?
No Yes (If “Yes”, please attach separate sheet explanation.)
6. Have you ever had any disciplinary actions taken against you by any state, federal, or
professional licensing board/agency, court, association or other professional group?
No Yes (If “Yes”, please attach separate sheet explanation.)
7. Have you ever resigned your membership in a state bar or other professional licensing
agency while disciplinary or criminal charges were pending?
No Yes (If “Yes”, please attach separate sheet with explanation.)
8. Have you ever had a judgment entered against you in connection with your role as an
attorney or as any other licensed professional?
No Yes (If “Yes”, please attach separate sheet with explanation.)
9. ADR Associations (List only current active memberships.)
Organization Name Member/Officer/Chair Years

VIII. PRO BONO REQUIREMENT
If approved as a member of either the Mediation, HENCE, Arbitration, or Small Claims
Panels, I agree to donate at least 8 hours pro bono services each year as referred by the
court. This requirement is a total contribution of 8 hours whether serving on one or more
panels.

IX. REFERENCES
If applying for the Mediation or Arbitration Panel, written recommendations are required from at
least three (3) individuals with personal knowledge of your mediation and/or arbitration skills.
For all other panels references regarding legal or professional skills and abilities are required.
Please contact the ADR Administrator with questions about the references.
Three recommendations/references are attached.
I will submit the required three recommendations/references within thirty (30) days of
notification that my application is otherwise approved.
X. FINAL SELECTION
Appointment to any of the Court’s ADR Program panels is at the sole discretion of the Court.

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Signature Date

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For Official Use Only

Date received: ______________ Initialed: ____ Initial questions or missing data: _________________________________________________________

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Date received additional information: ______________________ Initialed: ____ Date referred to ADR Application Subcommittee: ____________________ Date approved/disapproved: _______________ Date submitted to full ADR Committee: _________ Date approved/disapproved: _______________ Date letter sent to applicant: _____________

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