Form 522a - Mediator Application Form
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2STATE OF NEVADA
DEPARTMENT OF BUSINESS AND INDUSTRY - REAL ESTATE DIVISION
OFFICE OF THE OMBUDSMAN FOR COMMON-INTEREST COMMUNITIES AND CONDOMINIUM HOTELS
2501 East Sahara Avenue, Suite 202 * Las Vegas, NV 89104-4137
(702) 486-4480 * Toll free: (877) 829-9907 * Fax: (702) 486-4520
E-mail:
CICOmbudsman@red.state.nv.us
ALTERNATIVE DISPUTE RESOLUTION
MEDIATOR APPLICATION FORM
(Please Print or Type)
Name: ____________________________________________________________________________________
Address: __________________________________________________________________________________
City: ____________________________________ State: _________________ Zip: ______________________
Email address: _____________________________________________________________________________
Daytime number: ______________________ Fax: ______________________ Cell: ______________________
NEVADA BAR ID# _____________________ Current Member Status: _____________________________
Must be in good standing
Profession: ________________________________________________________________________________
Professional Certificates / Designations: _________________________________________________________
Qualifications:
List Mediation format training/certifications. Include copies of any Certified Mediator certificates with the application.
Course/Training Titles:_______________________________________________________________________
Date(s): __________________________________ Number of Hours: _________________________________
Provider Name/Address: _____________________________________________________________________
Completion Validation: ______________________________________________________________________
(Attach additional training if applicable)
Name of Mediation/Arbitration organization or service:
__________________________________________________________________________________________
Address: __________________________________________________________________________________
City: _______________________ State: ________________ Zip: ______________________
Phone: _____________________________________ Member Since: _________________________________
Revised 11/7/14
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522A
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