California > Local County > Los Angeles > Alternative Dispute Resolution
Application For Appointment To Alternative Dispute Resolution Panel ADR 006 - California
| Application For Appointment To Alternative Dispute Resolution Panel Form. This is a California form and can be used in Alternative Dispute Resolution Los Angeles Local County . |
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Superior Court of California County of Los Angeles Please return to: ALTERNATIVE DISPUTE RESOLUTION 111 North Hill Street, Room 113 Los Angeles, CA 90012 213-974-5425 CentralADR@LASuperiorCourt.org APPLICATION FOR APPOINTMENT TO ALTERNATIVE DISPUTE RESOLUTION (ADR) PANEL Please type or print the information on this form. Only complete applications will be processed. All items marked with a single asterisk (*) are confidential and not viewable by the public. PERSONAL INFORMATION (Mr./Ms./Mrs./Hon./Dr.) Name: Current Occupation: (Street) (Last) (First) (M.I.) Employed by (Firm/Office Name): (Suite) (City) (State) (Zip) Mailing Address (can be a post mailbox with physical street address, but not a U.S. post office box): Business Phone: Home Phone*(optional): Fax: Cell Phone*(optional): E-Mail: Private Fee Per Hour: RANDOM SELECT PANEL REQUEST (Check all panels for which you are applying. Panel (specify number) Neutrals with less than 1 year experience may request no more than 2 cases per month.) Panel (specify number) CIVIL Mediator Arbitrator Settlement Officer Neutral Evaluator** ____ case referrals per month ____ case referrals per month ____ days per year ____ case referrals per month ____ case referrals per month ____ days per year FAMILY LAW (non-custody) Mediator Arbitrator Settlement Officer Forensic CPA Settlement Officer ____ case referrals per month ____ case referrals per month ____ days per year ____ case referrals per month PROBATE Mediator Settlement Officer **Applicants must also complete the Supplemental Application for Appointment to Neutral Evaluation Panel (LAADR 074). I wish to receive referrals of the following type: On occasion I can accept cases on short notice. Unlimited Jurisdiction Limited Jurisdiction Small Claims I would like to act as a mentor for new panel members. LOCATION OF ADR SESSIONS For the ADR sessions, I prefer to use: Court facilities (applicants outside L.A. County must select at least 1 court facility at which they agree to conduct ADR sessions) Chatsworth Compton Glendale Long Beach Michael Antonovich (Lancaster) Norwalk Pomona South Santa Monica Stanley Mosk (L.A.) Torrance My private facilities Facilities of one of the parties' counsel ADA Accommodations*: (Neutrals may use LASC facilities for pro bono ADR sessions that require ADA accommodations. If you intend to use your own facilities to conduct the sessions, please indicate which, if any, of the ADA accommodations your facilities offer. This information will not be included in the neutral profiles viewable by the public but will be included in the Random Neutral Search criteria.) Accessible parking Accessible elevators Accessible public phones Accessible tables/counters EDUCATION Institution Degree or Certificate Major Start Date End Date Accessible entrance Accessible restrooms Assistive listening devices Other (specify): ____________________________ LAADR 006 (Rev. 07/11) LASC Approved 10-03 APPLICATION FOR APPOINTMENT TO ADR PANEL Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com LEGAL EXPERIENCE Are you actively engaged in the practice of law at this time? Current primary field of practice: Civil Family Number of years experience: Total active litigation ____ Both Plaintiff and Defense ____ EMPLOYMENT HISTORY (last 5 years) Employer Name and Location Yes No Probate Criminal Number of years: __________________ Simple case litigation ____ Plaintiff representation ____ Complex case litigation ____ Defense representation ____ Position Description Start Date End Date PROFESSIONAL LICENSES Type of License State Date Obtained License Number Status (active/inactive) Please attach a summary of your professional history limited to 600 characters, including punctuation and spaces. Yes No Has your license to practice law in California, or any other state, ever been suspended or revoked?* If yes, please attach a full explanation, including date(s) of suspension or revocation and date(s) of reinstatement. N/A Yes No Has any other professional license been suspended or revoked?* If yes, please attach a full explanation, including date(s) of suspension or revocation and date(s) of reinstatement for each such license. Have any disciplinary actions ever been taken against you by any state, federal, or professional licensing board/agency?* Yes No If yes, please attach a full explanation for each action including nature of offense, date of disciplinary action, length of sentence and/or probation and amount of restitution, if any. Yes No Have you ever been convicted of a felony or misdemeanor?* th If yes, please attach a listing of all convictions since your 18 birthday including offense, date and place of conviction and sentence, and date of release from custody and/or probation/parole. Driving under the influence must be reported. Have any sanctions of $1,000 or more been imposed against you by a court in any single case in the last 5 years, excluding Yes No discovery sanctions?* If yes, please attach a full explanation for each such case. Criminal or disciplinary actions will not automatically bar you from inclusion in the program. Each case is considered individually. However, failure to list criminal convictions or professional disciplinary actions taken against you will result in automatic removal from the program. ADR TRAINING Organization Course Title Hours Date ADR EXPERIENCE Number of years experience as: Mediator____ Arbitrator____ Settlement Officer____ Yes No Neutral Evaluator____ Are you currently or have you ever been on the Court ADR Panel? If yes, indicate dates (from-to): ____________ Transformative Facilitative Evaluative Mediation Work Style: Please attach a description of ADR style and requirements limited to 600 characters, including punctuation and spaces. Yes No Do you require participants to submit a brief? If yes, please attach a description of format and requirements limited to 600 characters, including punctuation and spaces. LAADR 006 (Rev. 07/11) LASC Approved 10-03 APPLICATION FOR APPOINTMENT TO ADR PANEL Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Number of ADR Proceedings Handled (Estimate) CIVIL PANELS: Check box for case types accepted Case Type Med Arb Set Conf Neutral Eval Antitrust/Trade Regulation Auto Tort Personal Injury/Property Damage/Wrongful Death (PI/PD/WD) Auto Tort Uninsured Motorist PI/PD/WD Civil Harassment Construction Defect Contract Breach of Rental/Lease Contract (not insurance, UD, or wrongful eviction) Contract
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