Ventura — Mediator Application

Source: https://ventura.courts.ca.gov/system/files/general/mediator_application.pdf

Superior Court of California County of Ventura

COURT-ORDERED CIVIL MEDIATION PROGRAM MEDIATOR APPLICATION

CONTACT INFORMATION

Name _____________________________________________ Date ___________

Address____________________________________________________________

City ______________________________ State ______ Zip Code _____

Telephone (Office) ___________________(Mobile) ________________________

E-Mail Address ______________________

OCCUPATION

Current Occupation___________________________________________________

Employed by________________________________________________________

Address____________________________________________________________

City __________________________________ State _______ Zip Code ________ (If applicable) How Long __________ Attorney Bar No. ________ Since _____

EDUCATION

School/College Course of Study Dates Degree/Certificates (Undergraduate)

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(Graduate/Law School)

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MEDIATION EXPERIENCE

List Mediation Training Program Completed: (Attach copies of certificates) ADR Training Organization Trainer Name # of Hours Dates

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Are you Currently a Mediator? Yes _____ No _____ In Private Practice Yes _____ No _____ With a Voluntary Agency Yes _____ No _____ With a Superior Court Yes _____ No _____ If yes, list where: ______________________________ List Mediation Organization/Agency/Professional Practice Mediation Experience: Dates Location & Telephone Type of Cases # of Cases Total Hours

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List Agencies or Organizations for which you are an Approved Mediator:

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Describe your areas of Expertise/Experience/Interests related to Mediation Bankruptcy Family Law Breach of Contract HOA and CC&R Business/Partnership Medical Malpractice Civil Rights Personal Injury Code Enforcement Probate Construction Defect Product Liability Discrimination Real Estate Employment/Labor Unlawful Detainer Environmental Other:

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VERIFICATION OF CIVIL MEDIATION EXPERIENCE List at least four (4) cases mediated within the past two (2) years.

1. Case No. ________________________________

Mediation Date ____________ Length of Mediation __________(at least 2 hrs)

Name of Plaintiff(s) __________________________________________________

Name of Defendant(s) _______________________________________________

Brief Description of Case

Mediation Outcome: ______ Full Settlement ______ Partial Settlement ______ No Settlement (If applicable) Organization ____________________ Co-Mediator Name __________________

Evaluator/mentor mediator ___________________ Telephone No. ___________

2. Case No. ________________________________

Mediation Date ____________ Length of Mediation __________(at least 2 hrs)

Name of Plaintiff(s) __________________________________________________

Name of Defendant(s) _______________________________________________

Brief Description of Case

Mediation Outcome: ______ Full Settlement ______ Partial Settlement ______ No Settlement (If applicable) Organization _____________________Co-Mediator Name __________________

Evaluator/mentor mediator ___________________ Telephone No. ___________

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3. Case No. ________________________________

Mediation Date ____________ Length of Mediation __________(at least 2 hrs)

Name of Plaintiff(s) __________________________________________________

Name of Defendant(s) _______________________________________________

Brief Description of Case

Mediation Outcome: ______ Full Settlement ______ Partial Settlement ______ No Settlement (If applicable) Organization _____________________ Co-Mediator Name __________________

Evaluator/mentor mediator ___________________ Telephone No. ___________

4. Case No. ________________________________

Mediation Date ____________ Length of Mediation __________(at least 2 hrs)

Name of Plaintiff(s) __________________________________________________

Name of Defendant(s) _______________________________________________

Brief Description of Case

Mediation Outcome: ______ Full Settlement ______ Partial Settlement ______ No Settlement (If applicable) Organization _____________________Co-Mediator Name __________________

Evaluator/mentor mediator ___________________ Telephone No. ___________

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PROFESSIONAL EXPERIENCE List Prior Occupation(s) or Business Experience: Employer Position Dates of Employment

Are you licensed in other professions or occupations? Occupation Licensing Agency State License No.

Current Membership(s) in Professional Organizations: Organization Position Dates

Multi-Lingual Abilities: Fluency in Languages other than English? Yes No Language Degree of Fluency

Have you been convicted of a felony and/or a misdemeanor involving moral turpitude? Yes No . (If so, explain:)

Other Relevant Information: (Use a separate sheet if needed.)

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ALTERNATIVE QUALIFICATION REQUEST

(If applicable) An applicant seeking placement on the Court’s Civil Mediator list who does not meet all the education, training, and experience requirements may still qualify if the applicant provides evidence of other sufficient education, training, skills and/or experience satisfactory to the court’s ADR Program Committee and Presiding Judge.

Please describe in detail below (and attach separate sheets if necessary) such other education, training, experience and/or skills:

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REFERENCES

List the Names of two (2) References (non-family) relating to your Mediation experience. (Include at least two professional references)

1. Name _____________________________________ Position ________________________

Organization __________________________________________________________________

Address ______________________________________________________________________

Telephone Number (Work)_____________________ (Mobile)__________________________

Describe Relationship

2. Name ______________________________________ Position ________________________

Organization ___________________________________________________________________

Address _______________________________________________________________________

Telephone Number (Work)_____________________ (Mobile)__________________________

Describe Relationship

VERIFICATION

By my signature below I declare under penalty of perjury that the information provided in this application is accurate and complete.

SIGN

Signature_______________________________ Date___________________

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