Mediator Application Form

MEDIATOR APPLICATION FORM

This Mediator Application (the Application) is submitted by Applicant Name: with Address: to Organization Name: on Date Submitted: .

RECITALS

WHEREAS, the Organization operates a roster of neutrals and evaluates applicants for appointment as mediators to provide dispute resolution services under the Organization's rules and administrative procedures; and

WHEREAS, the Applicant seeks to be considered for inclusion on the Organization's mediator roster and represents that the information submitted is true, complete, and accurate to the best of the Applicant's knowledge; and

WHEREAS, the Organization requires applicants to consent to background checks, disclose conflicts, and certify qualifications as a condition of appointment;

NOW, THEREFORE, the Applicant submits this Application and agrees to the terms, conditions, and declarations contained herein.

1. CONTACT AND IDENTIFICATION

2. PROFESSIONAL QUALIFICATIONS

3. MEDIATION TRAINING AND EXPERIENCE

4. PROFESSIONAL CONDUCT AND DISCLOSURES

Have you ever been the subject of professional discipline, license suspension, criminal conviction, or civil judgment relating to your professional conduct? No Yes

Do you anticipate any conflicts of interest with service as a mediator (current/prior representation, family relationships, financial interest)? No Yes

5. FEES, AVAILABILITY, AND PROCEDURES

Availability for appointments (check all that apply): In person Remote / Virtual Weekends

6. REFERENCES AND ATTACHMENTS

Check attachments included with this Application: CV / Resume Training certificates Other (describe below)

7. BACKGROUND CHECK AUTHORIZATION

The Applicant hereby authorizes the Organization and its designated agents to obtain and review criminal, civil, disciplinary, and professional records and other background information reasonably related to the Applicant's qualifications. The Applicant acknowledges that appointment to the roster is conditioned upon satisfactory background screening and ongoing compliance with Organization standards.

I certify under penalty of perjury that the foregoing statements are true and complete. I consent to background checks and to the Organization's verification of the information provided in this Application.

8. REPRESENTATIONS, INDEMNITY, AND LIMITATIONS

The Applicant represents and warrants that the Applicant is competent and qualified to serve as a mediator, will perform services in accordance with applicable professional standards and the Organization's rules, and will comply with confidentiality obligations. The Applicant agrees to indemnify and hold the Organization harmless from any claims arising from the Applicant's breach of these representations, except to the extent such claims arise from the Organization's gross negligence or willful misconduct. Nothing in this Application expands or limits legal liability beyond applicable law.

9. MISCELLANEOUS PROVISIONS

Governing Law: This Application and any appointment or agreement arising from it shall be governed by the substantive law of the jurisdiction in which the Organization operates, without regard to conflicts of law rules.

Entire Agreement: This Application, together with any accepted appointment, constitutes the entire understanding between the Applicant and the Organization with respect to mediator appointment and supersedes prior discussions and representations.

Severability: If any provision of this Application is held invalid or unenforceable, the remainder of the Application shall remain in full force and effect and shall be construed so as to effectuate the parties' intentions to the maximum extent permitted by law.

Notices: All notices required or permitted hereunder shall be in writing and delivered to the addresses provided in this Application or to other addresses later designated in writing by the parties.

Amendments and Waiver: Any amendment to this Application must be in writing and signed by both parties. Failure to enforce any provision shall not constitute a waiver of that provision.

Counterparts: This Application may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

10. CERTIFICATION

By signing below, the Applicant certifies under penalty of perjury that the information contained in this Application and any attachments is true, complete, and accurate, and that the Applicant will promptly notify the Organization in writing of any material change to the information provided.

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