Fill and Sign the Gs 7a 381 Page 17a 381 Mediated Settlement Form

Complete this section only if you are an attorney licensed in North Caro\ lina applying for certification to conduct mediated settlement conferences. 1. BAR ADMISSION I am a member in good standing of the North Carolina State Bar. Rule 8.B\ (1)(a)(i). I am am not currently suspended or disbarred from the practice of law by\ the attorney licensing authority of any state. Rule 8.B(1). I have have not been forced to forfeit my license to practice law in any s\ tate. Rule 8.B(1). 2. WORK EXPERIENCE I have at least five years of experience after date of licensure as a judge, practicing atto\ rney, law professor and/or mediator, or equivalent experience. 3. TRAINING (Complete only subsection (a) or subsection (b) below.) (a) I have completed at least forty (40) hours of trial court mediation tr\ aining in a program certified by the NC Dispute Resolution Commission. Rule 8.A. (Attach a copy of your certificate of training.) NOTE: If the program you attended has not been certified by the NC Dispute Res\ olution Commission, please submit copies of the agenda, trainer resumes, and all course materials. (b) I am currently certified by the NC Dispute Resolution Commission to cond\ uct family financial mediations in North Carolina and I have completed a 16-hour supplemental trial court mediation traini\ ng program certified by the NC Dispute Resolution Commission. Rule 8.A . (Attach a copy of your certificate of training.) APPLICATION FOR CERTIFICATION TO CONDUCT SUPERIOR COURT MEDIATIONS STATE OF NORTH CAROLINA Name And Address Of Applicant G.S. 7A-38.1; Rules Implementing Statewide Mediated Settlement Conferences and Other Settlement Procedures in Superior Court Civil Actions INSTRUCTIONS: Attorney applicants licensed in North Carolina complete Section I. Other attorney applicants complete Section II. Non-attorney applicants complete Section III. All applicants must complete the remaining sections. Please type or pr\ int and mail along with the required attachments to the NC Dispute Resolution Commission, PO Box 2448, Raleigh, NC 27602. Please enclose a check for your prorated certification fee made payable to the NC Dispute Resolution Commission. Effective July 1, 2018, the NCDRC will charge a $50.00 application proce\ ssing fee. For applications submitted within 12 months of your MSC mediator training, the application processing fee is $40.00. The Commission reserves the right to request additional information fro\ m applicants as needed to process their applications. (Over) I apply for certification as a mediator to conduct mediated settlement conferences in superior court pursuant to G.S. 7A-38.1 and the Rules Implementing Statewide Mediated Settlement Conferences and Other S\ ettlement Procedures in Superior Court Civil Actions. SECTION I. REQUIREMENTS FOR CERTIFICATION OF ATTORNEYS LICENSED IN NC Date Of Admission North Carolina Bar No. Dates Jurisdiction/Address Briefly Describe Experience Judge Practicing Attorney Law Professor Mediator Other Name Of Law School Location Of Law School Year Graduated SECTION II. REQUIREMENTS FOR CERTIFICATION OF ATTORNEYS LICENSED IN OTHER STATES Complete this section only if you are a licensed attorney not admitted i\ n North Carolina applying for certification to conduct mediated settlement conferences. 1. LEGAL EDUCATION AND BAR ADMISSION I am a graduate of the following accredited law school: Rule 8.B(1)(a\ )(ii). Program Title Date Of Training Training Conducted By Program Title Date Of Training Training Conducted By Date Of Birth Email Address Telephone No. Fax No. AOC-DRC-01, Rev. 4/18