Mediator Panelist Application Template Page 3
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6Superior Court of California, County of Sacramento
Mediation
ADR Training Programs Completed (Mediation, arbitration, neutral evaluation, other)
Dates (from - to)
Type of Training
Trainer’s Name
Number of Hours
ADR Experience (Please be cautious not to reveal confidential information)
Process Used
No. of Cases
Case Type
No. of Hours
Dates (from – to)
Agency
Are you currently an ADR neutral?
Yes
No
(If yes, check as many as apply and list all affiliations on the lines below)
Private Practice
Firm
Organization
Volunteer Agency
Court
Firm name:
ADR organization(s):
Volunteer agency(ies):
Court approved ADR list (Indicate which court ADR programs):
Other agencies or organizations for which you are an approved neutral:
Membership in Professional Organizations
Organization
Location
Years as Member
References
Please list persons with whom you have worked as a neutral. We encourage you to be mindful of
confidentiality and to seek prior permission to use these names. (Add pages if necessary). If you have not
worked as a neutral, list individuals as references who are familiar with your abilities and character.
1.
Attorney or
Client in:
Mediation
Arbitration
Neutral Evaluation
Other (Specify):
Name:
Position:
Organization:
Address:
Telephone Number:
Fax Number:
APPLICANT’S INITIALS: __________
Mediation Panelist Application
CV-E-MED-163 (Revised June 17, 2013)
Page 3 of 6
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