MEDIATOR APPLICATION FORM

PAGE 2

3. PROFESSIONAL LICENSES

TYPE OF LICENSE

STATE

DATE OBTAINED

LICENSE NUMBER

STATUS

4. LEGAL EXPERIENCE

SECTION III

ADR TRAINING / ADR EXPERIENCE

I. ADR TRAINING (Requirements: A minimum of 60 hours from providers recognized by the Valley Bar ADR Center; CE or CLE focused on mediation specific topics will be accepted. Training must include at least 30 hours of basic mediator training that meets all DRPA requirements, and at least 10 hours in role play or mediation simulation experience. Non-attorneys must demonstrate that they have had an additional 3 hours in training on litigation and court terminology, which may be from the same training or educational provider that provided all or part of the required 60 hours.)

BASIC TRAINING

ORGANIZATION

COURSE TITLE

HOURS

DATE / INSTRUCTOR

ADVANCED TRAINING

ORGANIZATION

COURSE TITLE

HOURS

DATE / INSTRUCTOR

II. EXPERIENCE (Requirements: Panelists must be able to substantiate that they have mediated a minimum of 100 cases. Applicants with a juris doctor degree from a law school or American Bar Association accredited law school or a graduate level degree in conflict resolution from a nationally or regionally accredited university may satisfy this requirement with 50 cases.)

c. Affiliations with provider or professional organizations (Example: LA Superior Court, ADR Services, EEOC)

ORGANIZATION / ENTITY

NUMBER OF YEARS

START

END

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