Mediator Panelist Application Template Page 4
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6Superior Court of California, County of Sacramento
Mediation
2.
Attorney or
Client in:
Mediation
Arbitration
Neutral Evaluation
Other (specify):
Name:
Position:
Organization:
Address:
Telephone Number:
Fax Number:
3.
Attorney or
Client in:
Mediation
Arbitration
Neutral Evaluation
Other (Specify):
Name:
Position:
Organization:
Address:
Telephone Number:
Fax Number:
OTHER INFORMATION
Have you ever been convicted of a violation of any federal law, state law, county or municipal law, or
ordinance?
Yes
No
If yes, please list on a separate sheet of paper all convictions since your 18th birthday including:
offense, date and place of conviction and sentence and the date of release from custody and/or
probation/parole as well as details of the offense. Driving under the influence must be reported.
Have you ever had any disciplinary actions taken against you by any state, federal, or professional
licensing board/agency, court, association or other professional group?
Yes
No
If yes, please describe on a separate sheet of paper the nature of the offense, date of disciplinary
action, length of sentence/probation and amount of restitution, if any.
Have you ever had a judgment entered against you in connection with your role as an attorney?
Yes
No
If yes, please describe the particulars.
APPLICANT’S INITIALS __________
Mediation Panelist Application
CV-E-MED-163 (Revised June 17, 2013)
Page 4 of 6
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