CASB — 325 West F Street, San Diego, CA 92101-6991 (CSD4001)

Source: https://www.casb.uscourts.gov/sites/casb/files/documents/forms/CSD4001.pdf

CSD 4001 [08/21/17] UNITED STATES BANKRUPTCY COURT SOUTHERN DISTRICT OF CALIFORNIA 325 West F Street, San Diego, CA 92101-6991

APPLICATION TO JOIN VOLUNTARY MEDIATION PANEL

Name: Phone Number:

Address:

Applicant is an attorney. California State Bar Number:

Pursuant to Administrative Procedures 5.2(a) Applicant has been admitted to practice in a Federal
Court for at least four years.

Are you a member of the United States District Court for the Southern District of California?
Yes – Date of Admission: No

List three bankruptcy matters in which you have either:
a. served as attorney of record from commencement to confirmation or discharge; or,
b. served as attorney of record for a party in interest in three or more adversary proceedings or
contested matters from commencement through completion (i.e.: judgment, order or stipulation).

Case Title Case Number Dates
1.
2.
3.

Applicant is not an attorney.
List three bankruptcy matters in which you have served as either:
a. Certified Public Accountant (licensed in the State of California) for a trustee or
debtor-in-possession or bankruptcy examiner; or
b. other substantially equivalent service.

Case Title Case Number Dates
1.
2.
3.

Applicant is a member of the Panel of Trustees maintained by the office of the United States Trustee.

Applicant has participated in a Mediation Training Program presented by :

I hereby certify that the undersigned meets the qualifications for membership to the Voluntary
Mediation Panel and that the foregoing is true and correct.

Dated: (Signature)

FORWARD TO: Clerk of the U.S. Bankruptcy Court, Southern District of California 325 West F Street, San Diego, California 92101 CSD 4001