Mediator Application Form

Please fill out the following application. Contact adr@ksd.uscourts.gov with any questions.

Contact Information

Name:

*
Format: Last, First M.I.

Firm/Office Name:

Firm/Office Address:

Phone:

Fax:

Email:

Website:

Bar Admissions

Kansas Bar #:

Kansas Bar Year:

Other Bars:

Are you a member in good standing in each jurisdiction where admitted to practice law?:

Good Standing?:

ADR Experience

Summarize your ADR experience, particularly in the last five years:

ADR Experience:

Within the past three years, list the number of sessions you participated in as:

Lead Mediator:

times

Co Mediator:

times

Counsel for Party:

times

ADR Training

Summarize your ADR training. Include Course Provider, Course Content, Date and No. CME Hours:

ADR Training:

Total No. of CME credit hours received within the preceding two years:

CME Hours:

State whether you are an approved mediator for civil cases pursuant to Kansas Supreme Court Rule 902(e)(3):

Approved Mediator?:

Legal Experience

Summarize your legal or other professional experience (including teaching), particularly in the past five years:

Professional Experience:

Please list the number of years you've spent in active litigation:

Years Litigating:

years

Within the past five years, list your percentage of practice representing:

Plaintiffs:

Defendants:

In Federal Court:

In State Court:

Please describe any other experience you have litigating:

Other Experience:

Please describe your legal and professional education (Include degree, school, year received):

Education:

Describe any other relevant information (e.g. publications, professional affiliations, awards, additional experience or skills):

Other Information:

Fee Structure

Describe your mediation fee structure:

Rate:

Compliance

This section will not be made publicly available.

I consent to public disclosure, including on the court's internet site, of the information above. (The court will post your profile only if you are accepted for the List of Mediators):

I agree?:

Have you ever:
been part of any civil, criminal or administrative proceeding charging you with conduct involving dishonesty, unethical conduct or commission of a crime? or
been disciplined or cited for a breach of ethics or unprofessional conduct by any court, administrative agency, bar association, or other professional group, excluding sanctions in an amount less than $1,000, imposed against you in a civil proceeding?

Answer:

If no, explain:

I have read the ADR Plan and will provide the disclosures set forth within section VII of the Plan

Answer:

I agree to participate periodically in court-approved ADR orientation or refresher training

I agree?:

I agree to permit participants in the mediation sessions I conduct to give feedback to the court about how the process was conducted

I agree?:

I agree to submit reports upon conclusion of the mediation

I agree?:

If requested by the court, I agree to serve as a mediator on a pro bono basis or, in the court's discretion, at a reduced fee in two cases per year

I agree?:

Use this area to provide any additional information for your application, if needed:

Additional Info:

All applications are screened for accuracy and qualifications before being posted. Submitting this application does not guarantee approval.