San Diego — Application to Serve as Mediator and/or Arbitrator CIV-023 (Rev: 01/24)

Source: https://sdcourt.ca.gov/sites/default/files/sdcourt/generalinformation/forms/civilforms/civ023.pdf

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SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN DIEGO

APPLICATION TO SERVE AS MEDIATOR AND/OR ARBITRATOR

APPLICATION COVER PAGE / CHECKLIST

Below is a quick-reference checklist for mediator and judicial arbitrator applicants which includes all items that must be submitted as part of an application to serve as a mediator or arbitrator in a civil case. For a complete list of requirements and additional information, refer to the Alternative Dispute Resolution - Mediator and Judicial Arbitrator Lists Policy (SDSC Form #CIV-417), which may be found on the court’s website at www.sdcourt.ca.gov.

A. Mediator List Application Checklist

Part A of the Application to Serve as Mediator and/or Arbitrator (SDSC Form #CIV-023). Certificate(s) of Completion and/or appropriate proof of all required training. See the Superior Court’s Alternative Dispute Resolution - Mediator and Judicial Arbitrator Lists Policy (SDSC Form #CIV-417) for requirements and additional information. Two letters of reference.

B. Judicial Arbitrator List Application Checklist

Part B of the Application to Serve as a Mediator and/or Judicial Arbitrator (SDSC Form #CIV-023). Certificate(s) of Completion and/or appropriate proof of training sufficient to demonstrate that the applicant is qualified to be a Judicial Arbitrator.

Return completed application(s) and all required documentation to: ADR Administrator Superior Court of California, County of San Diego Post Office Box 122724 San Diego, CA 92112-2724

Or by email to: MEDIATOR@sdcourt.ca.gov

SDSC CIV-023 (Rev. 1/24) APPLICATION TO SERVE AS MEDIATOR AND/OR ARBITRATOR Page 1 of 6 Mandatory Form

PART A. MEDIATOR LIST APPLICATION

Complete Part A if you are applying to be on the San Diego Superior Court Mediator List.

1. Applicant Information

   a. Name: b. Organization:

   c. Business address:

   City: State: Zip Code:

   Mailing address (if different):

   City: State: Zip Code:

   d. Email:

   e. Telephone number:

   f. Fax:

   g. Language(s) Spoken:

   h. I am an attorney licensed to practice law in California: NO YES, Bar #

   i. I am an attorney licensed to practice law in other state(s): NO YES, Bar # State:

2. Affiliation or Certification with Other Dispute Resolution Organizations List any certifications by other ADR organizations as a mediator or other type of neutral.

   Name of Organization Nature of Affiliation Number of Years

3. Education Provide postsecondary education information. Dates (from – to) College or University Degree Obtained

4. Mediation Training I have completed at least 32 hours of mediator training. Provide detail below demonstrating compliance with the court’s policy (SDSC Form #CIV-416)

   Training Provider Course Title or Certificate Hours Month/Year

Other Relevant Training (attach additional pages if necessary) Training Provider Course Title or Certificate Hours Month/Year

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5. Mediation Experience

   I have mediated at least eight cases of at least two hours in length within the past three years.

   Number Date
   Case Name Panel or Organization Case Type
   of Hours (Month/Year)

6. Mediation Areas of Experience Provide the approximate percentage of proceedings completed as a mediator in each of the following categories:

   TYPE % TYPE % TYPE %

   Business General Civil Legal Malpractice Construction Defect Healthcare Medical Malpractice Employment Insurance Personal Injury Environment Landlord/Tenant Real Estate Other

   I have been a trained mediator for: 1-2 Years 3-5 Years 6-10 Years More than 10 Years.

   I have mediated approximately cases since completing the minimum training required.

7. Other Experience as a Neutral, Arbitrator, or Settlement Attorney Panel or Organization Role Dates

8. References Provide three professional references:

   NAME: FIRM:

   ADDRESS: CITY: STATE: ZIP:

   PHONE: EMAIL:

   NAME: FIRM:

   ADDRESS: CITY: STATE: ZIP:

   PHONE: EMAIL:

   NAME: FIRM:

   ADDRESS: CITY: STATE: ZIP:

   PHONE: EMAIL:

   I have attached two letters of reference, one of which is from a party or attorney who appeared before me in a

   mediation.

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9. Facilities I will conduct mediation sessions in a professional facility that is appropriate for mediation. Location: I will accommodate persons with disabilities.

10. Insurance I have professional liability insurance. Provider: Policy #: I do not have professional liability insurance.

11. Compensation I agree to charge no more than $150 per hour for each of the first two hours in a limited civil action. I agree to charge $250 per hour for each of the first two hours in an unlimited civil action. I understand I will be compensated directly by the parties which will be shared equally by the parties, unless otherwise agreed upon. I agree to abide by San Diego Superior Court Local Rules, Division II, Chapter 3.

12. Prior Discipline or Convictions a. Have you ever been disciplined by the State Bar of California, a bar association, a public disciplinary or professional licensing agency, or an ADR organization or entity in any state or by a court of record, including but not limited to being sanctioned (other than being sanctioned for violation of the Civil Discovery Act) or held in contempt? Yes No (If yes, provide explanation):

    b. Do you have, or have you had, any disciplinary action pending against you by the State Bar of California, a bar association, a public disciplinary or professional licensing agency, or an ADR organization or entity in any state, or by a court of record, including but not limited to any proceeding for the imposition of sanctions (other than sanctions for violation of the Civil Discovery Act) or for contempt? Yes No c. Have you ever been suspended or removed as a mediator or ADR neutral, either temporarily or permanently, by a court or ADR organization? Yes No d. Have you ever been convicted or pleaded no contest to a felony or misdemeanor? Yes No e. Has there been a judgment against you in any civil action for actual fraud or punitive damages? Yes No f. Have you ever been a party to any legal proceeding? Yes No g. Have you ever been declared a vexatious litigant? Yes No

13 I understand and acknowledge that the selection and appointment of a mediator is solely at the discretion of the court for the purpose of assisting the public. Yes No

14. I have read and will comply with the court’s Alternative Dispute Resolution Program policy, as well as San Diego Superior Court Local Rules, Division II, Chapter 3, and California Rules of Court, rules 3.850 et seq., regarding Rules of Conduct for Mediators in Court-Connected Mediation programs for Civil Cases. Yes No

15. I have read and understand the Mediator Complaint Procedure found in San Diego Superior Court Local Rules, rule 2.3.2.1 and California Rules of Court, rule 3.865 et seq. Yes No

I declare under penalty of perjury under the laws of the State of California that the foregoing, including statements made in all attachments, is true and correct. I understand that any misstatement or omission of material fact may disqualify me from serving as a mediator and/or arbitrator in this court.

Date:

Type or print name Signature of Applicant

SDSC CIV-023 (Rev. 1/24) APPLICATION TO SERVE AS MEDIATOR AND/OR ARBITRATOR Page 4 of 6 Mandatory Form

PART B. JUDICIAL ARBITRATOR LIST APPLICATION

Complete Part B if you are applying to be on the San Diego Superior Court Judicial Arbitrator List.

1. Applicant Information

   a. Name: b. Organization:

   c. Business address:

   City: State: Zip Code:

   Mailing address (if different):

   City: State: Zip Code:

   d. Email:

   e. Telephone number:

   f. Fax:

   g. Language(s) Spoken:

2. Legal Practice and Experience

   I have been licensed to practice law in California for at least 10 years and am in in good standing. Yes No

   I am an active inactive member of the CA State Bar. Bar #

   I am also licensed to practice law in other state(s): Yes No, Bar # State:

Are you actively engaged in the practice of law at this time? Yes No

Number of years’ experience:

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

Plaintiff ___% Defendant ___%

Areas of practice [check box]: General Civil ___% Business ___% Personal Injury ___% Construction Defects ___% Landlord-Tenant ___% Consumer ___% Other ___% (please describe):

3. Professional Licenses Type of License Date Obtained License/Bar Number Status (active/inactive) CA Bar

4. Arbitration Training and Experience

   Arbitration Training Provide information about completed training which demonstrates qualifications to be a Judicial Arbitrator. Organization Course Title Hours Date

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Are you currently or have you been on a Judicial Arbitrator List in any other court(s)? Yes No If yes, provide date and name of court: Date Court

5. Provide affiliations with Alternative Dispute Resolution Organizations Name of Provider Organization Nature of Affiliation Number of Years

6. Provide the approximate number of proceedings completed as an arbitrator in each of the following categories

   Category # Category # Category #

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:

I declare under penalty of perjury under the laws of the State of California that the foregoing, including statements made in all attachments, is true and correct. I understand that any misstatement or omission of material fact may disqualify me from serving as a mediator and/or arbitrator in this court.

Date:

Type or print name Signature of Applicant

For Court Use Only

Approved Disapproved by Judge on . (date)

SDSC CIV-023 (Rev. 1/24) APPLICATION TO SERVE AS MEDIATOR AND/OR ARBITRATOR Page 6 of 6 Mandatory Form Clear This Form