Mediator Application

All Applicants

First Name/Middle Initial

Last Name

Firm

Office Street Address

City

State

Zip

Office Phone

Office Fax

Email

Website

California Bar Admission Date

State Bar No

Central District of California Admission Date

Other Bars

Bankruptcy Cases

List three bankruptcy cases in which you have served as the principal attorney of record (without regard to the party represented) from commencement to conclusion, or to the date of this application, whichever is earlier.

Case Title	Case Number	Dates	Representation

Adversary Proceedings

List three adversary proceedings or contested matters in which you have served as attorney of record for a party-in-interest from commencement through conclusion (i.e., judgment, order or stipulation), or to the date of this application, whichever is earlier.

Case Title	Case Number	Dates	Representation

Resolved Disputed Matters

List three matters in which you have resolved disputed issues in a mediation or other alternative dispute resolution format.

Case Title	Case Number	Dates	Representation

Non-Attorney Applicants

Resolved Matters

List three matters in which you have resolved disputed issues in a mediation or other alternative dispute resolution format.

Matter Description	Dates	Capacity Description

All Applicants

List any professional licenses you hold (other than bar admission), and include dates of admission in each profession.

List any professional organizations of which you are an active member, the length of your membership, and any positions held.

List any state or federal mediation or other ADR training that you have completed which has been qualified as continuing professional education credit or which has been approved by a court of competent jurisdiction. [NOTE: IT IS MANDATORY THAT ALL APPLICANTS CERTIFY HAVING COMPLETED AT LEAST 30 HOURS OF MEDIATION (NOT ARBITRATION) TRAINING PRIOR TO APPLYING FOR PANEL MEMBERSHIP.]

Have you been removed from any professional organization, or have you resigned from any professional organization while an investigation into allegations of professional misconduct was pending?
Yes No

If so, please explain the circumstances of such removal or resignation

Check the county(ies) in which you are willing and available to conduct mediation conferences:

Los AngelesOrangeSan BernardinoRiversideVenturaSanta BarbaraSan Luis Obispo

Specify any area(s) within the above couty(ies) in which you are not willing and/or available to conduct mediation conferences:
Panel Member Information Form

Occupation:

Education: [List institution(s), Degree(s) and Date(s)]

Mediation Training: [Number of hours & Name of Trainer]

ADR Organization Memberships: [e.g., Southern California Mediation Association, American Arbitration Association, etc.]

Description of Your Mediation Process/Approach: [e.g., Caucus/No Caucus; Directive/Collaborative; Evaluative/Facillitative; etc.]

Foreign Language(s) Spoken:

Certification

I hereby certify that I have read Third Amended General Order No. 95-01 entitled “In re Adoption of Mediation Program for Bankruptcy Cases and Adversary Proceedings” and that I meet the qualifications for membership to the Bankruptcy Mediation Program Panel.

If I am applying for appointment as an attorney mediator, I certify that I am a member in good standing of the state and federal bar(s) listed above.

If I am applying for appointment as a non-attorney mediator, I certify that I am a member in good standing of my profession.

I consent to disclosure of the information contained in this Application to Bankruptcy Court personnel and to the parties and their representatives whose matters have been referred to the Bankruptcy Mediation Program.