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Mediator Application - Oregon
| Mediator Application Form. This is a Oregon form and can be used in Circuit Court Multnomah Local County . |
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CIRCUIT COURT OF THE STATE OF OREGON Fourth Judicial District Civil Case Mediation Mediator Application Form Qualifications for civil case mediators are based upon the Judicial Department Court-Connected Mediator Qualifications Rules, issued as Chief Justice Order (CJO) 05-028, effective August 1, 2005. For more information regarding the CJO visit: http://www.ojd.state.or.us/web/OJDPublications.nsf/Files/05cER001sh.pdf/$File/05cER001sh.pdf Instructions for submitting this form are at the bottom of the final page. Please note: Shaded sections will appear on the Mediator Roster web-site as public information. General Information Applicant's Last Name: First Name, Middle Initial: Title: Mailing Address: OR Business Phone (1): Business Phone (2): Fax: E-Mail (1): E-Mail (2): Web Site: Current Employment Information Professional Memberships It is required that you attach diplomas, certificates or other forms of verification for the education and training described in the following two sections of the application: Basic Mediation Training and Court System Training. 1 of 4 | Page Civil Mediation Application Form - Version 1 American LegalNet, Inc. www.FormsWorkFlow.com Basic Mediation Training Basic Mediation Training (Minimum required: 30 hours) [Section 2.1(1) & 3.2] Description of Training Trainer(s) # of Hours Date(s) Del If you've not had Basic Mediation Training, describe substantially similar training or education. (Please note, experience as a mediator does not constitute "training".) Description of Training Trainer(s) # of Hours Date(s) Del Court Systems Training Describe your court system training. (Minimum required: 8 hours) [Section 3.5] Trainer(s) # of hours Date(s) Description of Training Del If you've not had 8 hours Court System Training, describe substantially similar training or education. Description of Training Trainer(s) # of hours Date(s) Del Other Mediation Training Enter description(s) of specialized or advanced mediation training. Description of Training Trainer(s) # of hours Date(s) Del Supervised Mediation Experience Describe your observations of an experienced mediator [in accordance with [Section 2.1(2)] in 3 court-connected civil case mediations. Date(s) Type of Case Location/Program Del Describe the mediations where you were observed by a qualified supervisor. 3 court-connected civil case mediations). Date(s) Type of Case [in accordance with Section 2.1(6)] in Location/Program Del Other Experience 2 of 4 | Page Civil Mediation Application Form - Version 1 American LegalNet, Inc. www.FormsWorkFlow.com Describe other relevant experience. Describe any special skills & experience you have. (e.g. second language proficiency, cultural sophistication, non-mediation related licenses or skills, other relevant education, etc.) Mediator Ethics [Section 1.4(1)] I adhere to the following organization's code(s) of professional ethics (e.g. OMA, OSB, ACR, AAA, etc). I certify that I include in my opening remarks to parties the required information specified in Section 1.4(3) of the CJO. (Initials) Types of Cases Mediated Indicate with a checkmark in the boxes below the types of cases you are willing and have the experience to mediate. No checkmark will indicate you are not willing to mediate those types of cases. Indicate in the second column the number of cases you have mediated in the types of cases you have checked. If any explanation is necessary, use the Comments column. Type Of Case Mediate? No of Cases Comments Business/Commercial Contract Employment Small Claims Landlord-Tenant Residential/ Commercial Real Property Tort Estate Disputes Trust Matters Guardianships/Conservatorships Construction Professional negligence General negligence Other Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 0 0 0 0 0 0 0 0 0 0 0 0 0 Compensation Information Describe Fees. 3 of 4 | Page Civil Mediation Application Form - Version 1 American LegalNet, Inc. www.FormsWorkFlow.com Are you willing to consider pro bono requests? Yes No OATH I hereby certify that I have reviewed and, if selected, will comply with the Oregon Revised Statutes, Uniform Trial Court Rules, and the Supplemental Local Rules for Multnomah County that pertain to civil case mediation. I affirm that I have reviewed the August, 2005, Chief Justice Order 05-028, describing the Judicial Department Court-Connected Mediator Qualifications Rules and that the above information is a true and accurate reflection of my qualifications as a mediator as outlined in that CJO. I acknowledge that my information may be verified, and that any references and/or programs listed above may be contacted. I expressly approve such investigation, and consent to the release of information about me from any relevant source. I agree to fulfill the continuing education requirement for court-connected mediators [Section 2.1(3) & 3.6] and all other requirements specified in the Chief Justice Order. I will keep the Mediation Commission informed of any changes in my contact information, licensure status or qualifications to be listed as a mediator. Signature Date Instructions for completed form: After the form has been completed, send the form data to the Courts by clicking the button below. (Please note that the Court will not process your application until it has received the e-mail with the form data file attachment. It is strongly recommended that you add your e-mail address as a recipient to the e-mail message created when the button below is clicked. If the original e-mail is not received by the Court, the message you send to yourself can be forwarded in it's place.) Next, print the completed form, date and sign it, then mail the signed form to: Mediation Coordinator Multnomah County Courthouse 1021 S.W. Fourth Avenue, Room 210B Portland, OR 97204-1123 Retain a copy for your records if desired. Questions? Call the mediation coordinator at 503-988-3318 or e-mail at mediation.coordinator@ojd.state.or.us 4 of 4 | Page Civil Mediation Application Form - Version 1 American LegalNet, Inc. www.FormsWorkFlow.com
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