Application Form For Applicants For Inclusion On Mediation Register (Lawyers Only) {MEDREGAP}

Application Form for Applicants for Inclusion on Mediation Register (Lawyers Only) United States Bankruptcy Court Eastern District of New York ----------------------------------------------------x In re: APPLICATION FOR INCLUSION ON COURT'S REGISTER OF MEDIATORS [For Lawyers Only] ----------------------------------------------------x I, the undersigned, hereby apply for inclusion on the Register of Mediators for the United States Bankruptcy Court for the Eastern District of New York. 1. Full name of applicant (list any former names and dates used): 2. Present business address and phone: 3. Please provide (in reverse chronological order) a brief description of all significant full-time employment experiences since graduation from law school: [Attach additional sheet(s) if necessary] American LegalNet, Inc. www.FormsWorkflow.com 4. Please list all colleges and professional schools that you attended, including (i) the dates of attendance, (ii) the addresses of the school, (iii) what degrees were received, and (iv) the date on which any degrees were received: [Attach additional sheet(s) if necessary] 5. Please list any special honors, scholarships, fellowships, honorary degrees and/or honorary society memberships that you received: [Attach additional sheet(s) if necessary] 6. List all courts in the United States or elsewhere to which you are admitted to practice, together with the dates of admission and lapses, if any: (Please also explain any lapses in membership.) [Attach additional sheet(s) if necessary] Page 2 of 5 American LegalNet, Inc. www.FormsWorkflow.com 7. Please provide a brief description of your practice as a lawyer: 8. Please provide a brief description of your experience and familiarity with bankruptcy law: 9. Please provide a brief description of your experience as a mediator or any other alternative dispute resolution experience that you may have: 10. Please describe all mediation training programs and/or courses that you have taken, setting forth (i) the title of the course, (ii) the name of the school or instructor, (iii) the sponsor, if any, of the program, (iv) the date(s) of the courses and/or programs, (v) the number of classroom hours, and (vi) the certification, if any, that was awarded: Page 3 of 5 American LegalNet, Inc. www.FormsWorkflow.com 11. Please list all professional organizations of which you are a member, including the dates of membership and whether or not you are an active member: 12. Please list any other pertinent experience, including, for example, relevant business or legal activities, public speaking activities and/or teaching experience: 13. 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 your answer is "yes" to any of the questions set forth in question 13, please explain in detail: 14. By making this application, I hereby certify that, if approved to serve as a mediator, I will not accept appointment as a mediator in any proceeding or matter unless at the time of appointment, I would (i) qualify as a "Disinterested Person" as defined by 11 U.S.C. § 101; (ii) not be disqualified pursuant to 28 U.S.C. § 455 assuming the same were to apply to a mediator; (iii) know of any other reason that would disqualify me as a mediator. 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. 15. By making this application, I hereby consent to the disclosure of the information contained herein, whether it be to Court personnel, the parties and/or their representatives, and to the public. Page 4 of 5 American LegalNet, Inc. www.FormsWorkflow.com 16. By making this application, I hereby consent to any inquiries that might be made concerning the veracity or accuracy of the information set forth herein, which the Court or any authorized Court personnel may make with any accrediting or licensing agency, any other public or private institution or any other entity or person listed herein, and I agree to cooperate with any such inquiry. I further agree that, if I fail to cooperate upon request, it may be a ground for disqualifying me as a mediator and removing my name from the Register of Mediators. 17. By making this application, I certify that I will fully comply with the relevant provisions of the Bankruptcy Code, the Federal Rules of Bankruptcy Procedure, and this Court's Local Rules and General Orders. 18. By making this application, I certify that I meet the qualification requirements set forth in the E.D.N.Y. Local Bankruptcy Rule 9019-1 governing mediation and mediators, except to the extent set forth below: 19. 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. If asked, I am willing to undertake five such assignments during the term of my appointment in cases pending in: Brooklyn Central Islip 20. I certify that I have not been affiliated with or employed by the Court during the 36-month period preceding the date of this Application. 21. Attached is a current original certificate of good standing from the Supreme Court of New York for the Appellate Division in which I am admitted. 22. Attached is a current original certificate of good standing from the United States District Court for the Eastern District of New York, or from one of the other District Courts of the Second Circuit. 23. I declare under penalty of perjury that the information provided in this application is true and correct. Dated: Signature of Applicant Page 5 of 5 American LegalNet, Inc. www.FormsWorkflow.com