Case Evaluator Application

MACOMB CIRCUIT COURT CASE EVALUATOR APPLICATION (Not to be used by ADR Mediator Applicants) Applicants may submit applications in teams of three for approval. If this is a team request, please list the last names of the other two applicants: To serve as a case evaluator in Macomb County Circuit Court, an applicant must meet the following minimum qualifications: An applicant must have been a practicing lawyer for at least five years. An applicant must be a member in good standing of the State Bar of Michigan. An applicant must reside, maintain an office, or have an active practice (litigation and/or mediation) in Macomb County. An applicant must demonstrate that a substantial portion of his/her practice for the last 5 years has been devoted to civil litigation matters including investigation, discovery, motion practice, case evaluation, settlement, trial preparation, and/or trial. An applicant must demonstrate an active practice for the last three years in the area of personal injury/negligence, medical malpractice, product liability, commercial, labor and employment, or complex commercial to qualify for those specialized sublists. Full Name P#__________________ __________________ Home Telephone No. __________________________________________________ Residence address __________________________________________________ Business address (if different from residence address) Current Employer's Name __________________ Business Telephone No. __________________________________________________ __________________________________________________ Previous Employer's Name Fax:_____________________ __________________ Number of years with employer Number of years with employer __________________ E-mail address: __________________________________ PART A: General Information New Application Renewal Application 1. When were you admitted to the practice of law (month/day/year)? 2. Are you a member in good standing of the State Bar of Michigan? Yes No 3. Have you ever been disciplined by the Michigan Attorney Discipline Board or any other 4/2/14 1 American LegalNet, Inc. www.FormsWorkFlow.com state or federal agency or court? If yes, explain on an attachment. Yes No 4. Have you served as a case evaluator? Yes No. If yes, please describe on an attachment. 5. Do you qualify for service in this jurisdiction by (a) residing in Macomb County (b) maintaining an office in Macomb County, or (c) an active practice in Macomb County? 6. Please provide factual support for your qualification(s) under question 5 by providing a description of your "active practice" on an attachment. 7. Please demonstrate that a substantial portion of your practice for the last 5 years has been devoted to civil litigation matters, including investigation, discovery, motion practice, case evaluation, settlement, trial preparation, and/or trial, as required by MCR 2.404(B)(2)(c) on an attachment. 8. Panel sought (select no more than two): General Civil Personal Injury/Negligence ( Plaintiff Medical Malpractice Product Liability Commercial Labor and Employment Complex Commercial ( Plaintiff ( Plaintiff ( Plaintiff ( Plaintiff ( Plaintiff Neutral Neutral Neutral Neutral Neutral Neutral Defense) Defense) Defense) Defense) Defense) Defense) PART B: For Specialized Lists Complete Part B if you are applying for service on a Specialized List (i.e. personal injury/negligence, medical malpractice, product liability, commercial, labor and employment, and complex commercial) pursuant to MCR 2.404(B)(4). 1. In your practice, do you primarily represent: 2. Plaintiffs Defendants Not identifiable Indicate the percent of your current practice in the following areas: Personal Injury/Negligence _____% Plaintiff _____% Defendant 4/2/14 2 American LegalNet, Inc. www.FormsWorkFlow.com Medical Malpractice Product Liability Commercial Labor and Employment Complex Commercial 3. _____% Plaintiff _____% Plaintiff _____% Plaintiff _____% Plaintiff _____% Plaintiff _____% Defendant _____% Defendant _____% Defendant _____% Defendant _____% Defendant Please demonstrate that you have had an active practice for the past 3 years in the area of law for the Specialized List you are applying as required by MCR 2.404(B)(2)(d) on an attachment. How many cases on average have you participated in case evaluation, facilitation, or mediation as counsel for a party over the last three years? . Have you previously served as a case evaluator, mediator, facilitator, or arbitrator in the past three years? . If so, please identify the forum, location and nature of case(s) heard, frequency of service, and whether you served as plaintiff, defendant, or neutral position. ______________________________________________________________________ ______________________________________________________________________ ___________________________________________________________________ How many cases did you resolve by way of settlement over the past three years on an annual basis?_____ Please specify the type of case. ______________________________________________________________________ ______________________________________________________________________ ___________________________________________________________________ Indicate the percent of your current practice: Mediation _________% Litigation ___________% 4. 5. 6. 7. 8. CASE EVALUATOR ELIGIBILITY CERTIFICATION I certify, pursuant to MCR 2.404(B)(1), that I meet the requirements for service under the Macomb County Circuit Court's selection plan and that I will not discriminate against parties, attorneys, or other case evaluators on the basis of race, ethnic origin, gender, or other protected personal characteristic. Date 4/2/14 Signature 3 American LegalNet, Inc. www.FormsWorkFlow.com GENDER/RACE/ETHNICITY INFORMATION - OPTIONAL In order to evaluate our efforts to provide bias free case evaluators and diversity, we ask you to voluntarily identify your gender/race/ethnicity. This information will be maintained separately from the other pages of the application. P Name (first, middle initial, last) (print or type) Bar No. Please check the appropriate box: Gender Male Female Race/Ethnicity American Indian or Alaskan Native Asian or Pacific Islander Black/African American (non-Hispanic) Caucasian (non-Hispanic) Hispanic Other Please specify Return this application to: Macomb County Circuit Court ADR Clerk 40 N. Main, 1st Floor Mt. Clemens, MI 48043 4/2/14 4 American LegalNet, Inc. www.FormsWorkFlow.com