Mediator Panelist Application Template Page 6
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6Superior Court of California, County of Sacramento
Mediation
V. CERTIFICATION OF APPLICANT:
I hereby certify that I have made full and accurate disclosure of all information requested in this
application form. I understand that any false, incomplete, or incorrect statement, regardless of when it
is discovered, may result in my disqualification or dismissal from the court approved mediation panel.
I hereby authorize all my employers and schools to release any and all information concerning me,
including information of a confidential and privileged nature. I HEREBY RELEASE ANY AND
ALL EMPLOYERS AND THE SUPERIOR COURT OF CALIFORNIA, COUNTY OF
SACRAMENTO, FROM ANY LIABILITY OR DAMAGE WHICH MAY RESULT FROM
FURNISHING THE INFORMATION REQUESTED.
While serving on the court approved arbitration panel, I acknowledge my responsibility to immediately
report any disciplinary action taken by the State Bar of California to the ADR Administrator.
My signature below further certifies that to the best of my knowledge I qualify for the position of
Mediator for the Superior Court of California, County of Sacramento.
Signature:
Date:
VI. REQUIRED DOCUMENTS:
i. Application – Original with signature and date
ii. Curriculum Vitae
Return the application and supporting documents to:
Arbitration Unit
Sacramento Superior Court
th
720 9
Street, Room 101
Sacramento, CA 95814
Mediation Panelist Application
CV-E-MED-163 (Revised June 17, 2013)
Page 6 of 6
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