San Mateo — Application for New ADR Civil Panelist

Source: https://sanmateo.courts.ca.gov/system/files/adr/panelist_new.pdf

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SAN MATEO COUNTY SUPERIOR COURT ADR PROGRAM NEUTRAL PANELS APPLICATION

APPLICANT (check all that apply):

Civil ADR Program: Mediator ☐ Neutral Evaluator ☐ Eligibility preferences: served as a mediator/evaluator in 10 matters

Probate ADR Program: Mediator ☐ Neutral Evaluator ☐ Eligibility preferences: served as a mediator/evaluator in 10 probate matters

Family Law ADR Program: Mediator ☐ Arbitrator ☐ Minimum eligibility: Licensed attorney; family law legal practice; served as a neutral in 10 matters Judicial Arbitration Program: ☐ Minimum eligibility: active membership in State Bar of California

APPLICANT INFORMATION

Name: Mobile Phone:

Email address: Phone:

Current residence address (Confidential):

CURRENT EMPLOYMENT/PRACTICE INFORMATION

Current employer or firm:

Employer/firm address:

City: State: ZIP Code:

Phone: Fax: URL:

Attorney: ☐ Non-Attorney Professional Mediator/Arbitrator: ☐ Retired Judge/Justice: ☐

EMERGENCY CONTACT (CONFIDENTIAL)

Name: Phone:

Address or Email address: Relationship:

EDUCATION

Institution:

Course of Study: Degree / Certificate:

Institution:

Course of Study: Degree / Certificate:

MEDIATION TRAINING

The minimum required training is a course consisting of 40 hours of continuous instruction by a sole provider that includes a significant role play component (~16 hours). Attach copy of proof of completion to application. Relevant experience may be substituted for this minimum training requirement on a case-by-case basis as appropriate.

Name of Institution / Instructor:

Number of hours completed: Date completed:

ADDITIONAL MEDIATION TRAINING Please include the provider, year, and number of hours of the training

LANGUAGE AND/OR BICULTURAL COMPETENCIES

Languages, other than English, in which you are comfortable conducting an ADR session:

Bicultural competencies and/or experience working with marginalized communities:

PROFESSIONAL REFERENCES

Please list individuals who know you in a professional context (as closely related to your work as an ADR practictioner as possible) who are familiar with your skills, training, background or experience. Please submit a letter of support for each reference named below.

(1) Name: Relationship:

Phone: Email address:

(2) Name: Relationship:

Phone: Email address:

(3) Name: Relationship:

Phone: Email address:

RELEVANT MEDIATION EXPERIENCE
Please list your experience in serving as a sole mediator in matters by completing the table below. The first entry is completed as an example.
Attach extra sheets as necessary; if completing as a word doc, expand last row with as many entries as necessary.

SPECIFIC ISSUES IN APPROXIMATE DURATION
TYPE OF MATTER NUMBER OF MATTERS WHEN CONDUCTED?
DISPUTE OF EACH

Wrongful termination; sexual
Employment 15 8+ hours 2015-2017
harassment

RELEVANT ARBITRATION EXPERIENCE
Please list your experience in serving as an arbitrator in matters by completing the table below. The first entry is completed as an example.
Attach extra sheets as necessary; if completing as a Word doc, expand last row with as many entries as necessary.

SPECIFIC ISSUES IN NUMBER OF APPROXIMATE DECISION BINDING?

TYPE OF MATTER WHEN CONDUCTED? DISPUTE MATTERS DURATION OF EACH Y/N

Wrongful termination;
Employment 6 20+ hours 2015-2017 4Y; 2N
sexual harassment

PROFESSIONAL HOURLY FEES

Hourly Mediation Fee: Hourly Arbitration Fee:

Hourly Neutral Evaluation Fee: Other Cost Passed on to Parties

All ADR panelists in MAP are required to provide one free session per year. Are you able to provide one free session per year. ☐ Yes ☐ No

CURRENT MEMBERSHIP IN PROFESSIONAL ORGANIZATIONS

CURRENT MEMBERSHIP ON NEUTRAL / ADR PANELS

PROFESSIONAL INSURANCE COVERAGE Attach policy declaration page to application.

Type of coverage: Policy limits:

Carrier name: Expiry date:

PROFESSIONAL LICENSES (NON-ATTORNEY) OPTIONAL – only if relevant to your ADR practice

Type of license: License number:

Date issued: Expiry date: State where issued:

How does this license apply to your ADR practice?

REQUIRED FOR ALL APPLICANTS:

Have you ever had a professional license suspended or revoked (includes license to practice law) ? ☐ Yes ☐ No Have you ever been subjected to disciplinary action by any licensing agency, public agency or ADR referral entity (includes State Bar)? ☐ Yes ☐ No

Explain any “yes” responses given in the section above:

Please describe your mediation style and/or your approach to mediation (for mediator applicants).

Please describe your approach to arbitration (for arbitrator applicants).

Please describe your approach to neutral evaluation (for neutral evaluator applicants).

What interests you in serving as a neutral on the San Mateo Superior Court panel(s)?

Non-attorney applicants: Please list your areas of subject matter expertise for which parties can engage your services.

Non-attorney applicants: please sign and date form and email to adr@sanmateocourt.org or mail to Superior Court, County of San Mateo, c/o Liliana Cervantes, ADR Division, 400 County Center, Redwood City, CA 94063.

Attorney/former member of the judiciary applicants: please continue to additional page; do not sign on this page.

Signature of non-attorney applicant: Date:

BAR ADMISSION INFORMATION

Active member of California State Bar? ☐ Yes ☐ No Date admitted:

California State Bar No. If inactive, date:

Admitted to Bar of another state? State:

Date admitted: Bar No. of other state:

Former member of the judiciary or former court commissioner? ☐ Yes ☐ No If yes, jurisdiction: Dates served:

LEGAL PRACTICE BY SUBJECT MATTER EXPERTISE

Percentage of
Percentage of Years of
practice in this Certified
current judicial
SUBJECT MATTER area – for all specialist in
practice in this experience in
years in this area?
area this area
practice

Personal Injury / Auto

Personal Injury / Other

Employment

Business / Breach of Contract

Real Estate / Eminent Domain

Wrongful Eviction

Probate: Estates & Trusts

Probate: Conservatorships, Guardianships & Elder Law

Construction Defect

Insurance

Legal Malpractice

Medical / Dental Malpractice

Environmental

Intellectual Property

Securities

Class Action / Complex Litigation

Landlord/Tenant

Family Law: Dissolutions, Child Custody & Visitation

Family Law: Domestic Violence

Family Law: Same Sex Unions

Other Subject Matter (Specify):

FOR JUDICIAL ARBITRATOR APPLICANTS ONLY: If your practice involves representing clients in personal injury matters, please indicate the percentage that are Plaintiffs: Defendants:

Attorney/Judicial Officer applicants: please sign and date form and email to adr@sanmateocourt.org or mail to Superior Court, County of San Mateo, c/o Liliana Cervantes, ADR Division, 400 County Center, Redwood City, CA 94063.

Signature of applicant: Date: