Mediator Qualification Questionaire

APPENDIX I (L.R. 7.05) MEDIATOR QUALIFICATION QUESTIONNAIRE Name__________________________________________________________________ Business Address_________________________________________________________ Telephone_______________________________________________________________ List any formal post-law school training for mediation (including seminars). Include the dates of the formal training: List the number of cases you acted as mediator: Check off the following areas you feel confident in mediating: Tort Commercial Products Liability Administrative Appeals Workers Compensation ___________________ ___________________ ___________________ ___________________ ___________________ American LegalNet, Inc. www.FormsWorkFlow.com List any professional associations affiliated with mediation: By submitting this application, I acknowledge I am familiar with Local Rule 7.05 on mediation, and I agree to comply with those rules. ___________________________________ Signature *This application must be submitted to: Manager, Court Administration Government Services Center 315 High Street, 3rd Floor Hamilton, Ohio 45011 American LegalNet, Inc. www.FormsWorkFlow.com