Santa Clara — Form CV-5016

Source: https://santaclara.courts.ca.gov/system/files/forms/cv-5016_rem.pdf

SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CLARA CIVIL EARLY SETTLEMENT CONFERENCE NEUTRAL BACKGROUND INFORMATION (PLEASE DO NOT ALTER THIS FORM IN ANY WAY. DO NOT ATTACH ADDITIONAL PAGES)

Name State Bar Number Email Address

Firm Name Phone Number Fax Number

Street or P.O. Box City Zip Code

1. a. Are you a member of the California State Bar? Yes No b. When were you admitted? c. What is or was the nature of your practice? d. What percentage of your practice has been representing plaintiffs defendants ?

2. Describe your education, including any ADR training you have received.

3. Check the boxes that describe your areas of practice:

   Business (Contract/Collection) Real Estate Labor/Employment Other (Specify): Personal Injury

4. Are you willing to conduct conferences: in Santa Clara County? Yes No at your office? Yes No during non-judicial hours? Yes No

5. Provide any other information that should be considered by parties or counsel.

   DECLARATION AND OATH

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. I have read the rules of the Civil Early Settlement Conference Program. I agree to serve as an early settlement conference neutral and to faithfully discharge my duties under this program. I agree to be paid by the Court a maximum flat rate of $150.00 per case for up to three hours of my time. I agree to make arrangements directly with counsel and parties regarding my compensation for any time over three hours. I agree to accept at least one pro bono case per year. I understand that the conference conducted under this pilot program is a settlement conference under California Rule of Court 3.1380, and not a mediation as defined in Evidence Code §1115. I understand that the provisions of Evidence Code §1115 et seq., including those which provide for confidentiality, nonadmissability, and nondisclosure, do not apply. I agree to waive any and all claims against the Superior Court of California, County of Santa Clara in connection with my services for this program.

Dated: Signed:

MAIL THIS FORM TO:

LAURIE MIKKELSEN, ADR ADMINISTRATOR

SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CLARA 191 N. FIRST STREET SAN JOSÉ, CA 95113 OR FAX TO 408-882-2595 OR EMAIL ADR@SCSCOURT.ORG

CV-5016 REV 11/8/2019 Page 1 of 1