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Application For Enrollment In Courts Panel Of Neutrals 5 - Mississippi
| Application For Enrollment In Courts Panel Of Neutrals Form. This is a Mississippi form and can be used in General District District Court Federal . |
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FORM 5 (ND/SD MISS. DEC. 2010) United States District Court _______________ District of Mississippi APPLICATION FOR ENROLLMENT IN COURT'S PANEL OF NEUTRALS Name: Firm Name: Office Address: City: E-Mail: State: ZIP Age: Tel: Fax: 1. 2. 3. Date admitted to The Mississippi Bar: Are you a member in good standing in The Mississippi Bar? Bar No: Yes No Have you ever been part of any legal proceedings, civil or criminal, charging you with moral turpitude or commission of a crime; or have you been disbarred, suspended from practice or otherwise disciplined by any court or administrative body; or have any proceedings been commenced against you by any court, administrative body, bar association, or grievance committee; or have you ever been refused admission to any bar or court? Yes No Attach to this application an affidavit giving complete details. 4. 5. Date admitted to the bar of this district court: List other courts, bars, or professional associations to which you have been admitted: 95 American LegalNet, Inc. www.FormsWorkFlow.com 6. Check the areas of legal practice or experience which best describe the majority of your legal practice and show the number of years of experience in each. Yrs Admin. Law Admiralty Antitrust Law Asbestosis Banking Law Bankruptcy Computer Law Other (specify) MEDIATION TRAINING U U Contracts Construction Law Criminal Law Civil Rights Debtor/Creditor Employment Environmental Yrs U Insurance Law Labor Law Medical Malpractice Oil & Gas Personal Injury Products Liability Securities Yrs 10. a. b. Hours of mediator training completed: Date(s) of mediator training, course provider, and summary of course content: Date Course Provider Content 96 American LegalNet, Inc. www.FormsWorkFlow.com c. Have you ever conducted mediation under the observation of another trained mediator? No Yes Date(s): Where? Summarize the event: 11. Have you ever trained mediators? Yes No When? MEDIATION EXPERIENCE 12. Number of mediation observations: Summarize the experience(s): Number of mediation sessions held to date: Summarize the session(s): 13. References as to your mediation skills, training, education, or other qualifications: 97 American LegalNet, Inc. www.FormsWorkFlow.com 14. Other references: I certify that the information provided in this application is true and correct. Date: Applicant's Signature Mail completed application to either of the following clerks: Clerk, U.S. District Court Northern District of Mississippi 911 Jackson Avenue, Room 369 Oxford, Mississippi 38655 Clerk, U.S. District Court Southern District of Mississippi P. O. Box 23552 Jackson, Mississippi 39225-3552 98 American LegalNet, Inc. www.FormsWorkFlow.com
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