Application For Five-Year Renewal Appointment On Courts Mediators Register {NYEB 5YRMR}}

Application for Five-Year Renewal of Appointment on the Register of Mediators for the United States Bankruptcy Court, Eastern District of New York (Lawyers) UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF NEW YORK ---------------------------------------------------------------------x In re: APPLICATION FOR RENEWAL OF APPOINTMENT ON THE COURT'S REGISTER OF MEDIATORS ---------------------------------------------------------------------x I hereby apply for renewal of my appointment on the Register of Mediators for the United States Bankruptcy Court for the Eastern District of New York and state as follows. 1. State your full name and list any former names used: 2. State your present business address, telephone, fax number and e-mail address: 3. 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, including a violation of Rule 11 or Rule 9011: _____ If you have answered "yes" to any of the above, please describe the circumstances on an attached page. 4. I certify that I will accept appointment as a mediator only if, at the time of appointment: (a) I would qualify as a "disinterested person" as defined by 11 U.S.C. § 101; (b) I would not be disqualified under the standards set forth in 28 U.S.C. § 455; (c) I am not aware of any other reason why I would be disqualified to serve as a mediator in the matter. American LegalNet, Inc. www.FormsWorkflow.com 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. 5. I consent to the disclosure of the information contained herein to Court personnel, the parties and/or their representatives, and the public. I consent to any inquiries that may be made concerning the veracity or accuracy of the information set forth herein by the Court or authorized Court personnel to any accrediting or licensing agency, any other public or private institution, or any other entity or person; and I agree to cooperate with any such inquiry. I acknowledge that if I do not cooperate with any such inquiry, then my application for renewal may be denied and my name may be removed from the Register of Mediators. I certify that I will comply with the relevant provisions of the Bankruptcy Code, the Federal Rules of Bankruptcy Procedure, and this Court's Local Rules and General Orders. I certify that I meet the qualification requirements set forth in E.D.N.Y. Local Bankruptcy Rule 9019-1. I understand that I may be requested from time to time to serve as mediator or mediation advocate in a case on a pro bono basis. I am willing to undertake at least three pro bono assignments during the term of my appointment in cases pending in: _____ Brooklyn 10. _____ Central Islip 6. 7. 8. 9. I certify that I have not been affiliated with or employed by the Court during the 36month period preceding the date of this Application. I certify that I am in good standing with the Supreme Court of New York for the Appellate Division in which I was admitted and with one of the United States District Courts within the Second Circuit. 11. I declare under penalty of perjury that the information set forth herein is true and correct. Dated: __________________________________________ Signature of Applicant Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com