Los Angeles local civil form — County of Los Angeles (1983-LASC CIV 307)

Source: https://lascpubstorage.blob.core.windows.net/forms/Forms%20Comprehensive%20List/1983-LASC%20CIV%20307.pdf

Superior Court of California PleaseAlternativereturnDisputeto: Resolution Office County of Los Angeles Superior320 WestCourtTempleof LosStreet,AngelesRoomCountyG-25 Los Angeles, CA 90012 Phone: (213) 830-0458 Email: MediationPanel@lacourt.ca.gov

APPLICATION FOR APPOINTMENT TO SUPERIOR COURT OF LOS ANGELES COUNTY’S MEDIATION VOLUNTEER PANEL

Please type the information on this form as you would like it to be displayed in your profile. Only complete and legible applications will be processed.

1. PERSONAL INFORMATION Name: (Mr./Ms./Mrs./Hon./Dr.) (Last) (First) (M.I.)

   Current Occupation:

   Mailing Address (can be a post mailbox with physical street address, but not a U.S. post office box): (Street) (Suite) (City) (State) (Zip)

   Primary Phone: Secondary Phone: E-Mail:

2. MEDIATION TRAINING I have completed a minimum of 25 hours comprehensive classroom and practical mediation training that meets California’s Dispute Resolution Program Act guidelines. If checked, please submit certification showing completion of the required mediation training.

   List Mediation Training Provider(s): Organization Course Title Hours Date Completed I am seeking admission to the panel and have not completed the required mediation training. I request to participate in the 25-hour mediation training provided by the Superior Court of Los Angeles County on Mediating the Litigated Case. In consideration of the free mediation training to be provided by Superior Court of Los Angeles County, I agree to accept and complete eight pro bono mediation assignments in a 24-month period.

3. MEDIATION EXPERIENCE Number of years of experience as a Mediator: None Less than 1 year 1-3 years 3-5 years 6-10 years more than 10 years I have mediated or co-mediated at least two cases within the past three years. No Yes In how many cases were you the sole mediator within the past three years? _____

Provide information for at least two cases you have mediated within the past three years: Panel or Organization Case Name Case Type Number of Date Mediated For Hours (month/year)

4. REFERENCES List two individuals who are familiar with your mediation skills or professional experience: Name: Firm: Address: City: State: Zip: Phone: Email: Relationship: Name: Firm: Address: City: State: Zip: Phone: Email: Relationship:

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5. LEGAL EXPERIENCE Are you actively engaged in practicing law at this time? Yes No

   California State Bar Number: __________________ Date Admitted: __________________

   Number of years of experience:
   Total active litigation: __________ Plaintiff representation: __________
   Simple case litigation: __________ Defense representation: __________
   Complex case litigation: __________ Both Plaintiff and Defense: __________

   Field of legal practice: Civil Number of years: __________ Family Number of years: __________ Probate Number of years: __________ Criminal Number of years: __________ Other: ____________________________ Number of years: __________

6. SUBJECT MATTER EXPERIENCE Indicate the areas in which you have subject matter and process expertise: Auto Other Personal Injury/Property Damage/Wrongful Death Breach of Contract/Warranty Other Real Property Business Tort Partnership & Corporate Governance Civil Rights Probate Collections Product Liability Defamation Professional Negligence Eminent Domain/Inverse Conversion RICO Family Law Uninsured Motorist Fraud Unlawful Detainer Insurance Coverage Writ of Mandate Medical Malpractice Wrongful Eviction Other Contract Wrongful Termination Other Employment Other: ____________________________________________

7. LANGUAGE CAPABILITIES List any languages, other than English, in which you can conduct a mediation: Armenian Russian Chinese - Cantonese Spanish Chinese – Mandarin Tagalog Korean Vietnamese Other (list all that apply):

8. EDUCATION Provide postsecondary education information: Institution Degree or Certificate Major Start Date End Date

9. EMPLOYMENT HISTORY Provide employment history for the last five years: Employer Name and Location Position Description Start Date End Date

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10. PROFESSIONAL LICENSES Provide professional licenses you hold: Type of License State Date Obtained License Number Status (active/inactive)

11. COURT ADR PANEL EXPERIENCE Are you currently or have you ever been on any Court ADR panel? Yes No If yes, detail below: Court Type of ADR Services Provided Start Date End Date (month/year) (month/year)

12. AFFILIATION WITH DISPUTE RESOLUTION PROVIDER ORGANIZATIONS List affiliations with dispute resolution providers, including any governmental entities: Organization Description of Affiliation Start Date End Date (month/year) (month/year)

13. MEDIATION FORMAT I have a subscription to the following virtual platform(s) to conduct mediation sessions:

    Webex Zoom Microsoft Teams Other remote platform: _____________________________

    Upon request, I will conduct mediation sessions in person. Please list the full physical address below.

    Note: Court facilities will not be offered for mediation sessions.

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Do you require participants to submit a brief? Yes No

How many volunteer assignments do you expect to be available to accept? 2 per year (minimum) 4 per year (minimum if SCLAC provides training) 5-10 per year more than 10 per year

On occasion, I can accept cases on short notice. I would like to act as a mentor for new panel members.

14. COMPENSATION I agree to provide three hours of virtual pro bono mediation plus preparation time for each case in which I am assigned as a mediator for the Superior Court of Los Angeles County’s Mediation Volunteer Panel. For cases where the parties request to continue after the three hours of pro bono mediation, my hourly rate for mediation is: $__________. I agree to notify the ADR Office if my hourly rate changes and will not charge more than the rate posted on the mediator profile listing. I am willing to provide a reduced hourly rate upon request.

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15. STATEMENT OF INTEREST Please provide a brief statement as to why you are interested in participating in the Superior Court of Los Angeles County’s Mediation Volunteer Panel:

16. HOW DID YOU LEARN ABOUT THE COURT’S MEDIATION VOLUNTEER PANEL? Notice to Attorneys Bar Association: _____________________________________________________________________________________ Individual: ___________________________________________________________________________________________ Other: ______________________________________________________________________________________________

17. PRIOR DISCIPLINE OR CONVICTIONS

    1. Has your license to practice law in California, or any other state, ever been suspended or revoked? Yes No If yes, please attach a full explanation, including date(s) of suspension or revocation and date(s) of reinstatement.
    2. Has any other professional license been suspended or revoked? Yes No If yes, please attach a full explanation, including date(s) of suspension or revocation and date(s) of reinstatement for each

    such license.

    3. Have any disciplinary actions ever been taken against you by any state, federal, or professional licensing board/agency? Yes No If yes, please attach a full explanation for each action including nature of offense, date of disciplinary action, length of

    sentence and/or probation and amount of restitution, if any.

    4. Have you ever been suspended or removed as a mediator or ADR neutral, either temporarily or permanently, by a court or ADR organization? Yes No If yes, please attach a full explanation, including date(s) of suspension or revocation and date(s) of reinstatement.
    5. Have any sanctions of $1,000 or more been imposed against you by a court in any single case in the last 5 years, excluding discovery sanctions? Yes No If yes, please attach a full explanation for each such case.
    6. Have you ever had a judgment entered against you in connection with your role as an attorney? Yes No If yes, please attach a full explanation for each such case.
    7. Have you ever been a party to any legal proceeding? Yes No If yes, please attach a full explanation for each such case.
    8. Have you ever been declared a vexatious litigant? Yes No
    9. Have you ever been convicted of a felony or misdemeanor? Yes No If yes, please attach a listing of all convictions since your 18th birthday including offense, date and place of conviction and

    sentence, and date of release from custody and/or probation/parole. Driving under the influence must be reported.

    Criminal or disciplinary actions will not automatically bar you from inclusion in the program. Each case is considered individually. However, failure to list criminal convictions or professional disciplinary actions taken against you will result in automatic removal from the program.

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18. AGREEMENT/CERTIFICATION If selected to serve on the Superior Court of California, Los Angeles County Mediation Volunteer Panel, I agree to:
    1. Provide preparation time and the first three hours of virtual mediation pro bono for each case in which I am assigned as a mediator by the Court's ADR Office. I understand that in the event the parties wish to continue the mediation beyond three hours, the parties will be responsible for payment at the hourly rate listed on the Court's website.
    2. Prepare for and conduct a minimum of two virtual pro bono mediation sessions in a 12-month period for cases assigned by the Court’s ADR Office (or eight cases in a 24-month period for those receiving Court-sponsored training). I understand that I am encouraged to mediate additional cases as availability permits.
    3. Comply with the General Rules Relating to Mediation of Civil Cases contained in California Rules of Court, rules 3.835 et seq. and 10.781 et seq.
    4. Comply with the Rules of Conduct for Mediators in Court-Connected Mediation Programs for Civil Cases contained in California Rules of Court, rules 3.850-3.860.
    5. Comply with the Local Rules of the Superior Court of California, County of Los Angeles and General Orders governing the Mediation Volunteer Panel.
    6. Submit certification showing completion of required mediation training to the Court's ADR Office with this application or upon request.
    7. Attend orientation and training sessions sponsored by the Court as required.
    8. Permit the Court to publish mediator profile and contact information on the Court’s website and in other publications as the Court sees fit.
    9. Be observed by ADR Office staff, with the consent of counsel and parties, during a mediation session.
    10. Report to the Court's ADR Office any criminal convictions promptly as well as any disciplinary action taken against me by any state, federal or professional licensing board and/or agency within five days of conviction or final decision of licensing board and/or agency.
    11. Not exploit my service as a court mediator by including reference to such position in any advertising, or on any letterhead, business card, telephone listing, or social media profiles (listing on a curricula vita is permissible).
    12. Acknowledge that selection and appointment to the Court’s Mediation Volunteer Panel is solely at the discretion of the Superior Court of California, County of Los Angeles for the purpose of assisting the public and does not constitute an employment relationship.
    13. Waive any claims against the Superior Court of California, County of Los Angeles, its judges, employees, and agents for damage, injury, or other harm arising from or connected to mediation services I rendered in a court-referred matter.
    14. Acknowledge that the Superior Court of California, County of Los Angeles does not provide liability or malpractice insurance for mediators on the Mediation Volunteer Panel.

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Executed on _____________________________ (date) at ______________________________________________ (city), California.

SIGN

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Signature

FOR ADR OFFICE USE ONLY
REVIEWED AUTHORIZED ADDED TO PANEL

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