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Application Form For Applicants For Inclusion On Mediation Register (Non Lawyer Professionals Only) - New York
| Application Form For Applicants For Inclusion On Mediation Register (Non Lawyer Professionals Only) Form. This is a New York form and can be used in Eastern District Bankruptcy Court Federal . |
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Application Form for Applicants for Inclusion on Mediation Register (Non-Lawyer Professionals Only)United States Bankruptcy Court Eastern District of New York ----------------------------------------------------xIn re: APPLICATION FOR INCLUSION ON COURTS REGISTER OF MEDIATORS [For Non-Lawyer Professionals Only] ----------------------------------------------------x I, the undersigned, hereby apply for inclusion on the Register of Mediators for theUnited States Bankruptcy Court for the Eastern District of New York. 1. Full name of applicant (list any former names and dates used): 2. Present business address and phone: 3. I consider myself a professional in the following field: 4. Please provide (in reverse chronological order) a brief description of allsignificant full-time employment experiences since graduation from college: 5. Please list all colleges and professional schools that you attended, including(i) the dates of attendance, (ii) the addresses of the school, (iii) what degrees were received, and(iv) the date on which any degrees were received:<<<<<<<<<********>>>>>>>>>>>>> 2 6. Please list any special honors, scholarships, fellowships, honorary degreesand/or honorary society memberships that you received: 7. List all licenses or professional accreditations that you have received or beenawarded in the United States or elsewhere, together with the dates of such licenses oraccreditations: (If there have been any lapses or suspensions in such accreditations, please sostate and explain.) 8. Please provide a brief description of your business practice: 9. Please provide a brief description of your experience and familiarity withbankruptcy law: 10. Please provide a brief description of your experience as a mediator or anyother alternative dispute resolution experience that you may have: 11. Please describe all mediation training programs and/or courses that youhave taken, setting forth (i) the title of the course, (ii) the name of the school or instructor, (iii) thesponsor, if any, of the program, (iv) the date(s) of the courses and/or programs, (v) the numberof classroom hours, and (vi) the certification, if any, that was awarded: 12. Please list all professional organizations of which you are a member,including the dates of membership and whether or not you are an active member: 13. Please list any other pertinent experience, including, for example, relevantbusiness or legal activities, public speaking activities and/or teaching experience: Page 2 of 4<<<<<<<<<********>>>>>>>>>>>>> 3 14. Please indicate yes or no as to whether you have (a) ever been suspended, disbarred, or had any professional license revoked: (b) any pending adverse actions against any of your professional licenses:_____ (c) ever been convicted of a felony: (d) ever been sanctioned or reprimanded by any tribunal for unethical or unprofessional conduct: If your answer is yes to any of the questions set forth in question 14, please explain in detail: 15. By making this application, I hereby certify that, if approved to serve as a mediator, I will not accept appointment as a mediator in any proceeding or matter unless at the time of appointment, I would (i) qualify as a Disinterested Person as defined by 11 U.S.C. 101; (ii) not be disqualified pursuant to 28 U.S.C. 455 assuming the same were to apply to a mediator; (iii) know of any other reason that would disqualify me as a mediator. I further certify that I will immediately contact the court to resign upon learning that I could no longer serve as a mediator because of disqualifications. 16. By making this application, I hereby consent to the disclosure of the information contained herein, whether it be to Court personnel, the parties and/or their representatives, and to the public. 17. By making this application, I hereby consent to any inquiries that might be made concerning the veracity or accuracy of the information set forth herein, which the Court or any authorized Court personnel may make with any accrediting or licensing agency, any other public or private institution or any other entity or person listed herein, and I agree to cooperate with any such inquiry. I further agree that, if I fail to cooperate upon request, it may be a ground for disqualifying me as a mediator and removing my name from the Register of Mediators. 18. By making this application, I certify that I will fully comply with the relevant provisions of the Bankruptcy Code, the Federal Rules of Bankruptcy Procedure, and this Courts Local Rules and General Orders. 19. By making this application, I certify that I meet the qualification requirements set forth in the E.D.N.Y. Local Bankruptcy Rule 9019-1 governing mediation and mediators, except to the extent set forth below: Page 3 of 4 <<<<<<<<<********>>>>>>>>>>>>> 4 20. I understand that I may be requested from time to time to serve as mediatoror mediation advocate in a case on a pro bono basis. If asked, I am willing to undertake threesuch assignments during the term of my appointment in cases pending in: Brooklyn Central Islip 21. I certify that I have not been affiliated with or employed by the Court duringthe 36-month period preceding the date of this Application. 22. I declare under penalty of perjury that the information provided in thisapplication is true and correct. Dated: Signature of Applicant Page 4 of 4
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