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Application For Mediator Recertification ADR-1003 - Virginia
| Application For Mediator Recertification Form. This is a Virginia form and can be used in ADR Supreme Court Statewide . |
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OFFICE OF THE EXECUTIVE SECRETARY SUPREME COURT OF VIRGINIA APPLICATION FOR MEDIATOR RECERTIFICATION Please use black ink so this document will be legible when scanned. This application will be considered pursuant to certification criteria established by the Judicial Council of Virginia and without regard to race, color, political affiliation, national origin, disability, sex or age. SECTION I GENERAL INFORMATION Please type or print. 1. Name: Last First Middle Business Name (if different from above): Primary Address: Street and/or Post Office Box State Zip Code County City 2. Last 4 digits SSN: 3. Phones/Home: E-Mail: Work: Fax: Certification Number: 4. Website: 5. Please check the type(s) of recertification for which you are applying: General District Court Juvenile & Domestic Relations District Court Circuit Court-Civil Circuit Court-Family 6. Please list all professional affiliations or activities that you consider relevant to your recertification. SECTION II CONTINUING EDUCATION AND MEDIATION All continuing education and mediations must have occurred since your original certification (if this is your first recertification) or since your last recertification date. To complete this section, choose the form(s) designated for the level of recertification you are seeking. See FORM ADR-1003/GDC/CCC and FORM ADR-1003/JDR/CCF. July 2011 FORM ADR-1003 1 American LegalNet, Inc. www.FormsWorkFlow.com SECTION III BACKGROUND 1. Have you ever 1) had a disciplinary action related to a profession, including mediation (for example, a professional license suspended or revoked); 2) had any professional privileges curtailed; and/or 3) relinquished a professional privilege or license while under investigation? Yes If Yes, No describe on the lines provided below. 2. Have you ever been convicted of, or plead guilty or nolo contendere to violations of the law, including traffic violations resulting in suspension or revocation of a driver's license and DUI offenses? Yes No If Yes, list on the lines provided below (please include the specific code section(s) isolated). 3. Please describe the impact, if any, that such conviction(s) could have on your ability to provide mediation services. SECTION IV EVALUATION AND CERTIFICATION (signature required below) I understand that in court-referred cases, if there is no orientation session provided for the parties by the court, I will provide an initial orientation session for the parties, and their lawyers if they choose to attend, at no cost to the parties. I understand that I am obligated as a condition of my continuing certification: (1) to familiarize myself with, and abide by, the Standards of Ethics and Professional Responsibility for Certified Mediators, adopted by the Judicial Council of Virginia effective July 1, 2011; and (2) to ensure that Forms ADR-1002 (Evaluation of Mediation Session(s) and Mediator(s)) are provided to all parties referred from the courts. I also hereby certify that the information provided in this application is true to the best of my knowledge and accurately reflects my qualifications to provide mediation services in cases referred through the court system of the Commonwealth of Virginia. I understand that all information herein is subject to verification. Signature of Applicant Date Please forward this application to: Dispute Resolution Services Office of the Executive Secretary 100 N. Ninth Street, Third Floor Richmond, VA 23219 Supreme Court of Virginia If you have any questions or comments, please contact Dispute Resolution Services, 804-786-6455. FORM ADR-1003 2 American LegalNet, Inc. www.FormsWorkFlow.com July 2011 Important Information Regarding the Recertification Process 1. Recertification of a mediator will be required every two years on November 1. Note that the first recertification date may be less than two years after initial certification, depending on the time of year you are certified. An applicant for recertification must complete and submit OES FORM ADR-1003 and FORM ADR-1003/GDC/CCC and/or FORM ADR-1003/JDR/CCF. General District and Circuit Court-Civil Mediation: An applicant for recertification as a General District or Circuit Court-Civil Mediator must submit evidence of cases mediated and training taken during the two-year period that falls between the last recertification date and October 31st of the year currently due for recertification. Juvenile and Domestic Relations and Circuit Court-Family Mediation: An applicant for recertification as a Juvenile and Domestic Relations District Court or Circuit Court-Family Mediator must submit evidence of cases mediated and training taken during the two-year period that falls between the last recertification date and October 31st of the year currently due for recertification. For casework proof, mediators may submit agreements to mediate, a case list from a case tracking system, a letter of verification from a colleague or case manager, a mediator signed referral or outcome form, evaluations, invoices, DC-40's signed by court personnel, MoA's, etc., as long as the date of the mediation and type of case is easily discernable from the document. Applicants for recertification may request approval by the Office of the Executive Secretary of training or education relevant to mediation practice they receive from organizations such as the Association for Conflict Resolution, the American Bar Association Section on Dispute Resolution, the Virginia Mediation Network, appropriate courses sponsored by the Virginia Committee on Continuing Legal Education, and others to meet the requirements for continuing education. When requesting approval, the applicant should submit an outline or agenda describing the content of the educational program. Mediators participating in an approved Peer Mediation Consultation Project program may receive up to four hours of general or family CME credit for attendance at such sessions. Mediators who provide either advanced general or family mediation skills training or present an advanced CLE seminar related to the subject of mediation may receive up to four hours of general or family CME credit. Evidence of providing such training, information on the length of the training, the number of times the training was offered during the recertification period as well as the number of hours spent in preparation for the course must be provided. 2. 3. 4. 5. 6. 7. 8. July 2011 Applicants who are unable to meet the requirements for number of complete case
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