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PRINT FORM CLEAR FORM Application for Arbitrator Registry – Individuals Only Information on this form and all attachments are subject to disclosure under the Texas Public Information Act. All or part of this information will be published in the Registry of Arbitrators or posted on a website available to the public. To be included on the Arbitrator Registry maintained by the Comptroller of Public Accounts, an agency of the State of Texas, a qualified arbitrator (applicant) must submit a completed application form and attachments to the Comptroller certifying that the applicant possesses the requisite credentials and certifications and agrees to perform the arbitration service for no more than $450 per arbitration. To remain on the Registry, a successful applicant must timely update any changes to his or her information. Applications must be completed by an individual; businesses may not apply on behalf of their employees. By submitting an application for inclusion in the Registry, each applicant acknowledges and understands that he or she must conduct each arbitration for which he or she is appointed in the manner required under applicable law, including without limitation, §§ 41A.08 and 41A.09, Texas Tax Code, and administrative rules and procedures adopted by the Comptroller. The applicant further acknowledges and understands that the requirements of Comptroller Rule 9.804 must be met and that the applicant does not violate Registry disqualifications regarding certain employment, public service, and other matters. Violation of the rule will result in the immediate removal of the arbitrator from the Registry. The $450 fee is the statutory maximum; all other expenses and costs must be borne by the arbitrator and the parties to the arbitration. As provided in the law and rule, the Comptroller shall appoint arbitrators, either by agreement of the parties or based on information provided in the application. By submitting an application, the applicant acknowledges and understands that inclusion in the Registry does not guarantee appointment for any minimum number of arbitrations. For Assistance - If you have any questions about this application, contact the Texas State Comptroller’s office at 1-800-252-9121. The local number in Austin is 512-305-9999. The email address is: ptad.cpa@cpa.state.tx.us Americans with Disabilities Act - In compliance with the Americans with Disabilities Act, this document may be requested in alternative formats by calling 1-800-252-9121. Federal Privacy Act - Disclosure of your Social Security number is required and authorized under law, for the purpose of tax administration and identification of any individual affected by applicable law. 42 U.S.C. §405(c)(2)(C)(i); Tex. Govt. Code §§403.011 and 403.078. Release of information on this form in response to a public information request will be governed by the Public Information Act, Chapter 552, Government Code, and applicable federal law. Public Information Act - Section 552.147, Tex. Govt. Code, excepts Social Security numbers from disclosure. If this form is requested as public information, your Social Security number will not be released. ARBITRATOR INFO. You have certain rights under Chapters 552 and 559, Tex. Govt. Code, to review, request and correct information we have on file about you. Contact us at the address or phone numbers listed on this form. • Type or print in black ink. • Do NOT write in shaded areas. 1. Taxpayer number for reporting any Texas tax OR Texas Identification Number if you now have or have ever had one ....................................................................... 2. Social Security number* (REQUIRED) ......................................................................................................................... * Your Social Security number is not subject to public disclosure according to Section 552.147, Tex. Govt. Code. 3. Individual’s first name, middle initial, last name, suffix (i.e., Jr., III, etc.) First name M.I. Last name Suffix 4. Mailing address, city, state, ZIP code with extension Street number, P.O. Box, or rural route and box number CONTACT INFORMATION City State/province ZIP code County (or country, if outside the U.S.) Phone number 5. Daytime phone number ................................................................................................................................. 6. Email address* ................................ *Your email address is confidential according to Section 552.137, Tex. Govt. Code; however, by including the email address on this form, you are affirmatively consenting to its release under the Public Information Act. FAX number 7. FAX number (optional) .................................................................................................................................. 8. Physical location Street number or rural route and box number (Do NOT use P.O. Box) City State/province ZIP code County (or country, if outside the U.S.) AP-218-1 (Rev.7-13/8) AP-218-2 (Rev.7-13/8) Page 2 9. Company name or affiliation (optional) Applicant certifies that he/she has completed at least 30 hours of training in arbitration and alternative dispute resolution procedures from the following university, college, or legal or real estate trade association and has attached a copy of the certificate to this application (Attorneys licensed by the State of Texas are exempt from this requirement.): Month Day Year 10b. PROFESSIONAL INFORMATION 10a. Applicant certifies that he/she has completed at least four hours of training approved by the Comptroller’s office regarding property tax law with an emphasis on the equal and uniform appraisal of property. (certificates attached) 11. Applicant certifies that he/she has a current license and/or certification and has attached a copy. If applicant has both a license and a certification, indicate which license or certification is primary. Renewals for the Arbitration Registry will be based on the expiration date of the chosen primary license or certification and completion of at least 8 hours of continuing education. An attorney licensed by the State of Texas ........................................................... State Bar No. PRIMARY A real estate broker or salesperson licensed under Chapter 1101, Occupations Code ....................................................................... License No. PRIMARY A real estate appraiser licensed under Chapter 1103, Occupations Code ........................................................ License No. PRIMARY TX- A certified public accountant licensed or certified under Chapter 901, Occupations Code .............................................................................. License No. PRIMARY 12. Applicant’s current areas of appraisal or real estate expertise (within last ten years) include: Residential ............................................................................................................................................................ Years of experience Commercial ........................................................................................................................................................... Years of experience Minerals ................................................................................................................................................................ Years of experience Agricultural ........................................................................................................................................................... Years of experience Land ...................................................................................................................................................................... Years of experience Business personal property ................................................................................................................................ Years of experience 13. Applicant is willing to arbitrate (check all that apply): In person, at any location within the region(s) or county(ies) indicated. By teleconference. As a desk review of documentation submitted by the property owner and appraisal district. 14. Applicant is willing to arbitrate for a maximum fee of up to $450. 15. From the table on the following pages select the region(s) and/or county(ies) in which you are willing to conduct arbitration. Applicants must complete the attached resume that includes information regarding educational background, past and present employment and information relevant to the applicant’s qualifications under the law and rules. As with all attachments to and information submitted with this application, resumes are public information under the Public Information Act and may be posted on a Web site. Applications may be mailed to: Texas Comptroller – Arbitrator Registry Application Property Tax Assistance Division Post Office Box 13528 Austin, Texas 78711-3528 In submitting this application, applicant agrees to: (a) conduct binding arbitration proceedings and issue awards according to applicable law, including but not limited to the requirements of §§41A.08 and 41A.09, Texas Tax Code, and administrative rules and procedures adopted by the Comptroller; (b) inform the Comptroller of any change to the information provided on this application in a timely manner; and (c) conduct each arbitration for which applicant is appointed by the Comptroller for a fee not to exceed $450 per hearing. IF APPLICANT MAKES A FALSE STATEMENT ON THIS FORM, IN ANY ATTACHMENTS TO THIS FORM OR IN ANY INFORMATION SUBMITTED TO THE COMPTROLLER UNDER APPLICABLE LAW AND RULES, APPLICANT COULD BE FOUND GUILTY OF A CLASS A MISDEMEANOR OR A STATE FELONY UNDER SECTION 37.10, TEXAS PENAL CODE. THE COMPTROLLER MAY REMOVE A PERSON FROM THE REGISTRY OF ARBITRATORS AT ANY TIME DUE TO FAILURE TO MEET STATUTORY QUALIFICATIONS OR TO COMPLY WITH REQUIREMENTS OF LAW OR ADMINISTRATIVE RULE OR FOR GOOD CAUSE AS DETERMINED BY THE COMPTROLLER. Month Date of signature Day Year AP-218-3 (Rev.7-13/8) Page 3 16. Social Security number* (Same as Item 2 on Page 1) ................................................................................................. * Your Social Security number is not subject to public disclosure according to Section 552.147, Tex. Govt. Code. PLEASE INDICATE BELOW REGIONS AND/OR COUNTIES WHERE YOU WOULD BE WILLING TO CONDUCT ARBITRATIONS (Please check boxes) To be an arbitrator statewide, check the “statewide” box only. Checking additional boxes will invalidate (cancel) the original selection. STATEWIDE To be an arbitrator for a designated region that covers “all” listed counties, check the “region” box only. Checking additional county boxes within the same designated region or statewide box will invalidate (cancel) the original selection. To be an arbitrator for designated county/counties that does NOT include the entire region, check the designated county box(es) only. An arbitrator may select multiple county boxes throughout various regions. An arbitrator may have the option to oversee an entire region AND individual counties from other regions. For example, an arbitrator may oversee the Capital Region and individual counties from the Central Texas Region. ALAMO REGION Atascosa Bexar Frio Guadalupe Kendall Medina Bandera Comal Gillespie Karnes Kerr Wilson Bastrop Burnet Fayette Lee Travis Blanco Caldwell Hays Llano Williamson CAPITAL REGION CENTRAL TEXAS REGION Bell Burleson Freestone Hill Limestone Mills Bosque Coryell Grimes Lampasas Madison Robertson Brazos Falls Hamilton Leon McLennan San Saba Milam Washington COASTAL BEND REGION Aransas Calhoun Goliad Jim Wells Lavaca Nueces Bee DeWitt Gonzales Kenedy Live Oak Refugio Brooks Duval Jackson Kleberg McMullen San Patricio Victoria GULF COAST REGION Austin Chambers Fort Bend Harris Matagorda Walker Brazoria Colorado Galveston Liberty Montgomery Waller Wharton HIGH PLAINS REGION Armstrong Collingsworth Garza Hockley Moore Roberts Bailey Crosby Gray Hutchinson Motley Sherman Briscoe Dallam Hale King Ochiltree Swisher Carson Deaf Smith Hall Lamb Oldham Terry Castro Dickens Hansford Lipscomb Parmer Wheeler Childress Donley Hartley Lubbock Potter Yoakum Cochran Floyd Hemphill Lynn Randall AP-218-4 (Rev.7-13/8) Page 4 PLEASE INDICATE BELOW REGIONS AND/OR COUNTIES WHERE YOU WOULD BE WILLING TO CONDUCT ARBITRATIONS (Please check boxes) To be an arbitrator for a designated region that covers “all” listed counties, check the “region” box only. Checking additional county boxes within the same designated region or statewide box will invalidate (cancel) the original selection. To be an arbitrator for designated county/counties that does NOT include the entire region, check the designated county box(es) only. An arbitrator may select multiple county boxes throughout various regions. An arbitrator may have the option to oversee an entire region AND individual counties from other regions. For example, an arbitrator may oversee the Capital Region and individual counties from the Central Texas Region. METROPLEX REGION Collin Denton Fannin Hunt Navarro Rockwall Cooke Ellis Grayson Johnson Palo Pinto Somervell Dallas Erath Hood Kaufman Parker Tarrant Wise NORTHWEST TEXAS REGION Archer Coleman Foard Kent Runnels Taylor Baylor Comanche Hardeman Knox Scurry Throckmorton Brown Cottle Haskell Mitchell Shackelford Wichita Callahan Eastland Jack Montague Stephens Wilbarger Clay Fisher Jones Nolan Stonewall Young Zavala SOUTH TEXAS BORDER REGION Cameron Hidalgo La Salle Starr Webb Dimmit Jim Hogg Maverick Uvalde Willacy Edwards Kinney Real Val Verde Zapata SOUTHEAST TEXAS REGION Angelina Jasper Newton Sabine San Jacinto Trinity Hardin Jefferson Orange San Augustine Shelby Tyler Houston Nacogdoches Polk UPPER EAST TEXAS REGION Anderson Cherokee Harrison Marion Red River Upshur Bowie Delta Henderson Morris Rusk Van Zandt Camp Franklin Hopkins Panola Smith Wood Cass Gregg Lamar Rains Titus El Paso Hudspeth Jeff Davis Presidio UPPER RIO GRANDE REGION Brewster Culberson WEST TEXAS REGION Andrews Crockett Howard Mason Reagan Terrell Borden Dawson Irion McCulloch Reeves Tom Green Coke Ector Kimble Menard Schleicher Upton Concho Gaines Loving Midland Sterling Ward Crane Glasscock Martin Pecos Sutton Winkler AP-218-5 (Rev.7-13/8) Page 5 RESUME INFORMATION FOR ARBITRATOR REGISTRY • TYPE OR PRINT IN BLACK INK • USE NON-COLORED PAPER ONLY • DO NOT ATTACH ADDITIONAL MATERIALS FOR COMPTROLLER USE ONLY ARBITRATOR INFORMATION Individual’s first name, middle initial, last name, suffix (i.e., Jr., III, etc.) First name M.I. Last name Suffix EDUCATION Type of School Name and Location of School Date Graduated Type of Diploma or Degree Fields of Study Undergraduate Colleges or Universities Graduate Schools Technical, Vocational or Business Schools TRAINING In addition to the arbitration training that you were required to complete in order to qualify as an arbitrator for property tax appeals, list professional training that you have completed in property appraisal, real estate sales or other areas related to property valuation. PROFESSIONAL ORGANIZATIONS Please list all professional organizations from which you have a license or certificate or to which you belong. AP-218-6 (Rev.7-13/8) Page 6 EMPLOYMENT BACKGROUND FOR COMPTROLLER USE ONLY Please list your previous employment, starting with your most recent job first. Do not list any experience from more than ten (10) years previous. Position title Employer Location Length of work Description of duties Position title Employer Location Length of work Description of duties Position title Employer Location Length of work Description of duties Position title Employer Location Length of work Description of duties CIVIC AND COMMUNITY ORGANIZATIONS List any organizations to which you currently belong. OTHER INFORMATION Do you speak a language other than English? If “YES,” what language(s) do you speak? YES NO