Napa — Mediator Application

Source: https://www.napa.courts.ca.gov/system/files/mediator-application.pdf

SUPERIOR COURT OF CALIFORNIA COUNTY OF NAPA

APPLICATION TO SERVE AS CIVIL MEDIATOR

Please return completed application to:

Superior Court of California, County of Napa 825 Brown Street Attn: Civil Mediation Application Napa, CA 94559

1. Contact Information

Name: CA Bar #:

Employer:

Business Address:

City: State: Zip:

Mailing Address (If different):

City: State: Zip:

Email:

Telephones: Daytime: Evening: Fax: Cell:

2. Areas of Expertise and Facilities

I have subject matter experience in the following areas (check all that apply):

Business Construction Defects Employment Environment Family Law General Civil Healthcare Insurance Landlord/Tenant Legal Malpractice Medical Malpractice Personal Injury Probate, Trusts Real Property and Estates Other:

I am fluent in the following language(s):

APPLICATION TO SERVE AS CIVIL MEDIATOR www.napa.courts.ca.gov

May 1, 2015

SUPERIOR COURT OF CALIFORNIA COUNTY OF NAPA

APPLICATION TO SERVE AS CIVIL MEDIATOR

3. Education

Please provide the following information on your postsecondary education (not including classes/training not leading toward a degree):

Dates (from – to) University Degree Obtained

4. Legal Practice and Experience

Are you an active member of the California State Bar? 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 N/A N/A N/A

5. Disciplinary Actions and Criminal History

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

misdemeanor.

If you have, please explain fully:

APPLICATION TO SERVE AS CIVIL MEDIATOR www.napa.courts.ca.gov

May 1, 2015

SUPERIOR COURT OF CALIFORNIA COUNTY OF NAPA

APPLICATION TO SERVE AS CIVIL MEDIATOR

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:

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 as summarized below

   I have completed at least one basic/introductory mediator training course consisting of 10 hours of classroom training (attach additional pages if necessary).

   Organization Course Title Hours Month/Year

   I have completed at least 10 hours of experiential training (e.g., role playing, as outlined by the California Dispute Resolution Programs Act guidelines, 16 Cal. Code of Reg. section 3622(d)).

   Organization Course Title Hours Month/Year

   I have conducted three or more mediations of two hours or more during the preceding three years.

   APPLICATION TO SERVE AS CIVIL MEDIATOR www.napa.courts.ca.gov

   May 1, 2015

SUPERIOR COURT OF CALIFORNIA COUNTY OF NAPA

APPLICATION TO SERVE AS CIVIL MEDIATOR

I have shadowed a qualified mediator who meets the qualifications to be on the Napa County mediation

panel for three mediations of two hours or more during the preceding three years.

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

If you do not have the training and/or experience required above, describe in detail in an attachment your training and experience in conducting mediations that demonstrates your abilities and competence in the field of mediation.

NUMBER OF MEDIATION PROCEEDINGS COMPLETED: Bankruptcy Family Law Personal Injury – Other Business/Corporate General Civil Premises Liability Civil Rights Homeowners Association Probate, Trusts and Estates 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 False Imprisonment Personal Injury - Auto Other

Have you served on a Court Mediation Panel in any other court? Yes No If yes, please provide dates and locations:

COURT ADR PANELS. Attach additional pages if necessary.

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

AFFILIATION WITH OTHER DISPUTE RESOLUTION ORGANIZATIONS Name of Provider Organization Nature of Affiliation Number of Years www.napa.courts.ca.gov

May 1, 2015

SUPERIOR COURT OF CALIFORNIA COUNTY OF NAPA

APPLICATION TO SERVE AS CIVIL MEDIATOR

7. References.

Please provide two references who have appeared before you in mediation as a party or attorney.

NAME: FIRM:

ADDRESS: CITY: STATE: ZIP:

PHONE: FAX: EMAIL:

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

NAME: FIRM:

ADDRESS: CITY: STATE: ZIP:

PHONE: FAX: EMAIL:

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

8. Compensation

I am willing to accept a reasonable hourly fee after 3 hours of Pro Bono mediation service. YYes NNo

My current hourly rate for mediation is:

9. Certification

A copy of my resume is attached to this application. I am a member in good standing of the State Bar of California. I have read and will comply with the Court’s Civil Mediation 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.

If offered appointment to the Civil Mediation Panel for the Superior Court, State of California, County of Napa, 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:

Signature:

APPLICATION TO SERVE AS CIVIL MEDIATOR www.napa.courts.ca.gov

May 1, 2015