Fill and Sign the Criteria for Admission to the Roster of Mediators for Economic Form

CRITERIA FOR ADMISSION TO THE ROSTER OF MEDIATORSFOR ECONOMIC ASPECTS OF FAMILY LAW CASES Mediation Training Successful completion of 40 hours of mediation training approved by the Joint Credentials Committee, or completion of a minimum of 25 hours of mediation training and an additional 15 hours within one year after admission to the roster. Education/ Professional Experience 1 )a . Juris Doctor (or equivalent law degree); b . Admission to the Bar for at least seven years; c . Licensed to practice law in the state of New Jersey; and d . Practice substantially devoted to matrimonial law. or 2 )a . Advanced Degree in Psychology, Psychiatry, Social Work or allied Mental Health field, Business, Finance, or Accounting, or a CPA; b . At least seven years experience in the field of expertise; and c . Licensed in New Jersey if required in the field of expertise. Annual Continuing Education Following completion of the total requirement of 40 hours mediation training, attendance at a minimum of four hours of annual continuing education as set forth under Rule 1:40-10(b) 3.1. Application Review Process Applications will be reviewed by a Joint Credentials Committee of the Supreme Court Committee on Complementary Dispute Resolution and the Supreme Court Family Practice Committee. * PLEASE INCLUDE COPIES OF TRAINING CERTIFICATES Revised 06/21/2004, CN 10488-English page 1 of 2 APPLICATION FOR ADMISSION TO ROSTER OF MEDIATORSFOR ECONOMIC ASPECTS OF FAMILY LAW CASES LAST NAME FIRM / BUSINESS NAME MIDDLE NAME FIRST NAME Return the above five items and this form to: Harry T. Cassidy Family Division Administrative Office of the CourtsPO Box 983 Trenton, NJ 08625 FIRM / BUSINESS ADDRESS CITYSTATE ZIP CODE TELEPHONE NUMBER ( ) - DEGREES ATTAINED (post high school) YEAR AREA OF CONCENTRATION NAME OF INSTITUTION PROFESSIONAL LICENSE(S) (specify type and when obtained) YEAR OF ADMISSIONTO PROFESSIONALPRACTICE MEDIATION TRAINING (attach addtional sheet if necessary) Provider(s) Date(s) NUMBER OF YEARS DOING MEDIATIONNUMBER OF MEDIATIONS IN PAST 5 YEARS HOURLY FEE PRIMARY COUNTIES OF PRACTICE NUMBER OF YEARS OFEXPERIENCE FOR ATTORNEYS: PERCENT OF PRACTICE DEVOTED TO MATRIMONIAL LAW I certify that the foregoing statements made by me are true and that I am in good standing in my profession. SIGNATURE 6 CERTIFIED MATRIMONIAL ATTORNEY YES NO Hours FAX NUMBER( ) - HAVE YOU EVER BEEN DISCIPLINED IN YOURPROFESSION YES NO (if yes, attach explanation) YES NO DO YOU HAVE MALPRACTICE INSURANCE BAR ADMISSION YEAR NEW JERSEY: _________ OTHER STATES: _________ Course Title Please attach the following: 1. Resume or Curriculum Vitae 2. Description of mediation training courses 3. Descriptive paragraph (please provide a maximum of 50 words about your mediation and other relevant professional experience that will be transferred directly to the roster if you are accepted) 4. Subject area(s) of mediation experience 5. List of professional organizations in which you are an active member. PRIMARY COUNTIES OF PRACTICE FOR NON-ATTORNEYS:PERCENT OF TIME DEVOTED TO FAMILY MATTERS Revised 06/21/2004, CN 10488-English page 2 of 2