Mediators Declaration Of Interest And Qualification (Page 2 of 4) in pdf

Mediators Declaration Of Interest And Qualification Page 2

Section 2

Pursuant to ICMSC Rule 8(c), I, the above named mediator, request that the North

Carolina Industrial Commission place my name on the list of mediators with similar

qualifications which the Commission makes available to parties selecting mediators for

WORKERS’ COMPENSATION CASES / STATE TORT CLAIMS CASES / BOTH

(indicate one). My pertinent qualifications and experience are:

______________________________________________________________________________

I have successfully completed the following mediation training:

Date of training

Course title and hours of training

Provider

______________________________________________________________________________

If the training was not certified by the Dispute Resolution Commission or sponsored by a Center belonging to the Mediation Network

of North Carolina, please attach a copy of the training agenda and a list of the trainers.

I will notify the Commission if and when any of the above declarations or

qualifications listed above no longer obtain.

This the ___ day of _________ ,_____.

_________________________________

Signature of Mediator

Please indicate how many hours (one-way) you are willing to drive to conduct

mediation conferences in cases in which you are appointed as the mediator by the

Commission:______________________________________

Mediators Declaration Of Interest And Qualification Page 2