Orange — Application for Civil Mediation Panel

Source: https://www.occourts.org/system/files/general/application-civil-mediation-panel.pdf

Application to Serve as Civil Mediator

SUPERIOR COURT OF CALIFORNIA COUNTY OF ORANGE

Please return completed Application to: Superior Court of California, County of Orange Attn: Richard Augustine 700 Civic Center Drive West, D-100 P.O. Box 838 Santa Ana, California 92702-0838

1. Contact Information

Name: California State Bar number:

Employer:

Business Address:

City: State: Zip:

Mailing Address (If different):

City: State: Zip:

E-mail:

Telephones: Daytime: Evening: Fax: Cell:

2. Areas of Experience and Facilities I have subject matter experience in the following areas (check all that apply):

   Business Construction Defects Employment Environment
   General Civil Healthcare Insurance Landlord/Tenant
   Legal Malpractice Medical Malpractice Personal Injury Real Estate
   Other:_ _____________________________________________________________________

   I am fluent in the following language(s): Spanish Vietnamese Other: I have a facility within Orange County where I can conduct mediation sessions. APPLICATION TO SERVE AS CIVIL MEDIATOR

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State Bar Number:

Your name:

3. Education Please provide the following information on your postsecondary education. Attach additional pages if necessary.

Dates (from – to) University Degree Obtained

4. Legal Practice and Experience (Minimum Requirement: Current Member of CA State Bar – 10 Years)

   Have you been an active member of the California State Bar for the past ten years? Yes No

   Are you actively practicing law at this time? Yes No If yes, number of years:

   If you primarily represent either the plaintiff or the defendant, please indicate:

   Plaintiff Defendant

   Professional Licenses. Please provide the following information for each professional license you

   have received. Attach additional pages if necessary.

   State License/Bar Number Date Obtained Status (active/inactive)

California

5. Disciplinary Actions and Criminal History

   I have have not been charge with, pleaded guilty or no contest to, or convicted of, a felony or

   misdemeanor.

If you have, please explain fully:

I have have not been suspended or subject to disciplinary action as a result of an investigation

from any professional organization, public entity or mediation program.

If you have, please explain fully: ___ ___________________________________________

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APPLICATION TO SERVE AS CIVIL MEDIATOR

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State Bar Number:

Your name:

I am am not aware of any pending disciplinary action against me by any professional

organization, public entity or mediation program.

If you are, please explain fully:

6. Mediation Training and Experience

   I have completed at least 30 hours of mediator training, including:

   At least one basic/introductory mediator training course consisting of ten (10) hours of classroom training. Attach additional pages if necessary.

   Organization Course Title Hours Month/Year

   Ten (10) hours of experiential training (e.g., role playing, as outlined by the California Dispute Resolution Programs Act guidelines). Attach additional pages if necessary.

   Organization Course Title Hours Month/Year

   APPLICATION TO SERVE AS CIVIL MEDIATOR

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State Bar Number:

Your Name:

Five (5) hours of advanced training or specialized training (e.g., bar association or other MCLE

programs pertaining to mediation skills). Attach additional pages if necessary.

Organization Course Title Hours Month/Year

OTHER RELEVANT TRAINING (Including Temporary Judge Training). Attach additional pages if necessary. Organization Course Title Hours Month/Year

I have been a trained mediator for: 1-3 years 3-5 years 6-10 years more than 10 years

APPLICATION TO SERVE AS CIVIL MEDIATOR

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State Bar Number: Your name:

6. Mediation Training and Experience (continued)

Have you served on a Court Mediation or Neutral Evaluation Panel in any other court(s)?

Yes No If yes, please provide dates and locations:

Have you applied for the Superior Court of Orange County Temporary Judge program and been turned

down?

Yes No

COURT ADR PANELS. Attach additional pages if necessary.

From To
Court ADR Panel Type (Month/Year) (Month/Year)

AFFILIATION WITH OTHER DISPUTE RESOLUTION ORGANIZATIONS. Attach additional pages if necessary.

Name of Provider Organization Nature of Affiliation Number of Years

NUMBER OF MEDIATION PROCEEDINGS COMPLETED. Please provide the approximate number of proceedings completed as a mediator in each of the following categories:

Bankruptcy False Imprisonment Personal Injury - Auto
Business/Corporate General Civil Personal Injury – Other
Civil Rights Homeowners Association Premises Liability
Collections Immigration Product Liability
Construction Insurance Coverage Property Liability
Contract/Breach Intellectual Property Real Property/Real Estate
Eminent Domain Labor Securities
Employment– Discrimination Landlord-Tenant Tax
Employment – Termination Legal Malpractice Trademarks/Secrets
Entertainment Maritime Unfair Competition
Environmental Medical Malpractice Wrongful Death
Fraud Partnership Other:

APPLICATION TO SERVE AS CIVIL MEDIATOR

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State Bar Number: Your name:

6. Mediation Training and Experience (continued)

   I have mediated at least 8 cases within the past 3 years, as specified in Section 12.c of the Civil

   Mediation Program Guidelines, as follows:

   Case Name Panel or Organization Mediated Case Type Number Date
   For of Hours (Mo/Year)

   In how many of the cases listed above were you the sole mediator?

7. References

   a. List two or more attorneys who are familiar with your work and have appeared before you in a mediation:

NAME: FIRM:

ADDRESS: CITY: STATE: ZIP:

PHONE: EMAIL:

RELATIONSHIP TO CASE (ATTORNEY OR PARTY):

NAME: FIRM:

ADDRESS: CITY: STATE: ZIP:

PHONE: EMAIL:

RELATIONSHIP TO CASE (ATTORNEY,OR PARTY):

b. Provide an additional reference who is familiar with your mediation skills:

NAME: FIRM:

ADDRESS: CITY: STATE: ZIP:

PHONE: FAX: EMAIL:

RELATIONSHIP TO CASE (ATTORNEY, PARTY OR CO-MEDIATOR):

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State Bar Number: Your name:

8. Insurance

   I have or will obtain and maintain insurance covering services as a mediator naming the Superior Court as an additional insured. If you have such insurance, attach a copy of the Certificate of Insurance to this application. If you do not currently have such insurance, you will be required to provide a copy of the required Certificate of Insurance prior to having any mediation cases referred to you.

9. Compensation

   I am willing to accept a fee of $300 for up to 2 hours of a mediation session. Yes No

My current hourly rate for mediation is:

10. Certification

    A copy of my resume is attached to this application. A copy of my fee deposit policy is attached to this application. I am a member in good standing of the State Bar of California. (initial)______ I have read and will comply with the Court’s Civil Mediation Pilot Program Guidelines and the California Rules of Court, rule 3.850 et seq., regarding Rules of Conduct for Mediators in Court- Connected Mediation Programs for Civil Cases. (initial)_____

    I hereby accept my appointment to the Civil Mediation Panel for the Superior Court, State of California, County of Orange. I agree to serve and to abide by all the applicable statutes, court rules, local rules and program guidelines. I will use my best effort to discover and disclose to the parties any conflict of interest or potential conflict I may possess. I understand that I have an ongoing duty to disclose any changes to my responses in Section 5.

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

Date: Print name:

SIGN

Signature:

APPLICATION TO SERVE AS CIVIL MEDIATOR

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