Fillable Form 522a- Referee / Arbitrator Application Form (Page 2 of 2) in pdf

Name of Mediation/Arbitration organization or service:

__________________________________________________________________________________________

Address: ____________________________

City: ___________________________ State: _____ Zip: _________

Phone: ______________________________

Member Since: _________________________________________

Please describe any experience with the resolution of homeowner association disputes. If no experience, please enter N/A:

__________________________________________________________________________________________

Geographic Service Area:

☐

Reno/Carson/Tahoe Area

Central Nevada

☐

Northeastern Nevada

Greater Las Vegas Area

Please list foreign languages, or sign language, in which you have sufficient fluency to serve as a neutral:

__________________________________________________________________________________________

Fee and Expenses:

$200 per hour, not to exceed a total of

_____________

I acknowledge that my rate will be a maximum of

$1,000 per Referee hearing.

_____________

I acknowledge that Mediation proceedings may be subsidized by the Division as per NAC

116.520 in an amount not to exceed $500 or $250 for each party who is eligible for subsidy,

whichever is less.

_____________

I acknowledge that Referee proceedings are subsidized to the extent funds are available.

_____________

Should I be appointed to the ADR Mediation panel, I acknowledge that as per NRS 38.330(2), all

mediations are to be conducted at the maximum rate of $500 for no more than (3) hours. Any

additional mediation time must be agreed upon by all parties involved, and the rate of this

additional time is to be no more $200.00 per hour.

_____________

I CERTIFY that the above information and any other information I am submitting for this

application is true and correct to the best of my knowledge and that I may be removed from the

Referee panel or the approved Division Neutral List for intentionally falsifying the information

provided. False certification may also subject me to civil or criminal penalties. I understand that

all of the information provided is a public record. I agree to comply with all provisions of NRS

Chapter 38.

_____________

If I am listed on the Division Neutral List, I agree to perform resolution services to the best of my

ability in an ethical and proper manner and in accordance with the time provisions of the Referee

process.

______________

I acknowledge that unless otherwise agreed to by the parties, the referee is appointed on a rotating

basis within the discretion of the Division.

________________________________________

__________________________________

_____________

Signature

Print Name

Date

STATE OF ____________________________ ___

ss. COUNTY OF ___________________________________

I certify that this is a true and correct copy of a document is possession of ________________________________

PRINT NAME

_________________________ ______

__________________________

Notary Signature

Commission Expiration:

Revised 11/7/14

Page 2 of 2

522A

Form 522a- Referee / Arbitrator Application Form Page 2

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