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Mediation Panel Application Form ADR-19 - California

Mediation Panel Application Form Form. This is a California form and can be used in ADR USDC Central Federal .
 Fillable pdf Last Modified 2/3/2014
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UNITED STATES DISTRICT COURT CENTRAL DISTRICT OF CALIFORNIA MEDIATION PANEL APPLICATION FORM Pursuant to Central District of California General Order 11-10, I am applying for appointment to the Mediation Panel. As a condition of service on the Mediation Panel, I agree not to make reference to being a member of the Mediation Panel on a business card, letterhead, or while seeking elective office. The following information is supplied in support of this application: Name: LAST FIRST MIDDLE Check one: New Application Re-Application (check one): No new information is submitted from my previously submitted application(s). If this box is checked, please initial and date where indicated at the end of this section and fax this page only to the ADR Program Office at 213-894-5084 or scan and return by e-mail to ADR_Coordinator@cacd.uscourts.gov. DATE INITIAL Additional/Amended information is submitted on this application; this application is to be attached to my previously submitted application(s) which is in the custody of the ADR Program Office. (Note to applicant - It is not required that you submit additional/amended information in order to be reappointed to the Panel. Such information will only be used to keep your internal file current.) If this box is checked, please date and sign the application on page three and fax it in its entirety, along with any supplemental material, to the ADR Program Office at 213-894-5084 or scan and return by email to ADR_Coordinator@cacd.uscourts.gov. Business: FIRM NAME BUSINESS TELEPHONE EXTENSION STREET ADDRESS SUITE BUSINESS FAX CITY STATE ZIP CODE BUSINESS E-MAIL ADDRESS State Bar Memberships: STATE BAR ID NUMBER DATE OF ADMISSION STATE BAR ID NUMBER DATE OF ADMISSION STATE BAR ID NUMBER DATE OF ADMISSION STATE BAR ID NUMBER DATE OF ADMISSION Date Admitted to the Bar of this Court: Total number of years of legal practice: Of total caseload, percentage of cases personally handled in federal court within the last five (5) years: % Please list most significant cases personally handled in federal court, excluding pro per representation (list no more than five): ADR-19 (01/14) APPLICATION MEDIATION PANEL Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Areas of Legal Practice: INDICATE ALL THAT APPLY AND THE LENGTH OF TIME PRACTICED IN EACH AREA Admiralty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Americans with Disabilities Act of 1990 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alternative Dispute Resolution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Antitrust . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bankruptcy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Business - Commercial Litigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Civil Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Class Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Consumer Credit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Copyright - Trademark . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Employment - Discrimination - Wrongful Termination . . . . . . . . . . . . . . . . Environmental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ERISA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Foreclosure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Individuals with Disabilities Education Improvement Act (IDEIA) . . . . . . Insurance Coverage - Bad Faith . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Labor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Patent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Personal Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Product Liability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Professional Negligence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Real Estate - Construction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Securities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Transportation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Please provide a brief statement as to how you have demonstrated your expertise in the above-mentioned areas of law and why you consider yourself qualified to be appointed to the Central District's Mediation Panel: Please provide a brief statement as to your trial, litigation, and ADR experience: How did you learn about or who referred you to this Panel? ADR-19 (01/14) APPLICATION MEDIATION PANEL Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Please provide the names, addresses and telephone numbers of three (3) references (who the reviewers may contact) who are members of the Bar of the United States District Court for the Central District of California: (1) NAME BUSINESS ADDRESS BUSINESS TELEPHONE EXTENSION CITY STATE ZIP CODE OTHER NUMBER (HOME, MOBILE, ETC.) (2) NAME BUSINESS ADDRESS BUSINESS TELEPHONE EXTENSION CITY STATE ZIP CODE OTHER NUMBER (HOME, MOBILE, ETC.) (3) NAME BUSINESS ADDRESS BUSINESS TELEPHONE EXTENSION CITY STATE ZIP CODE OTHER NUMBER (HOME, MOBILE, ETC.) There are formal dispute resolution training requirements for all Panel members. To assist the court, please indicate one of the following: No, I have not attended formal dispute resolution training. Yes, I have attended formal dispute resolution training as follows: DATE(S) OF TRAINING HOURS COMPLETED COURSE PROVIDER COURSE NAME DATE(S) O
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