Potential Additions to Mediation Rule

OPTIONAL Form A

APPLICATION FOR ADMISSION TO
OUT-OF-COURT MEDIATION PROGRAM ROSTER

General Instructions

(1) Each applicant must read the Rules of the Out-of-Court Mediation Program.
(2) If additional space is needed to respond fully to any item on this application, please set forth the response(s) on a separate page with an identification of the question number to which it responds, sign each such additional page, and attach hereto.
(3) Please send with this application a diskette that contains a true copy of this application in a version of software acceptable to ADRO.

Name: _______________________________________________________________________

Firm: ________________________________________________________________________

Office Address: ________________________________________________________________

Street ________________________________________________________________________

City State Zip Code __________________________________________________

Office Phone: ________________    Office Fax: __________________

E-Mail: ____________________________________

Bar I.D. or other Professional Association I.D. _________________________________

7. Have you been removed from any professional organization, or have you resigned
from any professional organization while an investigation into allegations of professional misconduct was pending?

Yes ____ No ____

If so, please explain the circumstances of such removal or resignation.

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

8. Check the province(s) in which you are willing to conduct mediation proceedings:

_____ ______________________ _____ ________________________________

_____ ______________________ _____ ________________________________

I hereby certify that I have read the Rules of the Out-of-court Mediation Program, that I meet the qualification set forth therein for admission to the ADRO Roster of Mediators, and that I will fully comply with the relevant provisions of the Rules and ADRO internal procedures and forms and any modifications thereto, relating to out-of-court Mediation.

I will immediately contact the ADRO, and any parties for whom I have accepted appointment as a Mediator, upon learning I am no longer qualified to serve pursuant to the provisions of the Rules.

If I am applying for appointment as an attorney Mediator, I certify that I am a member in good standing of the _______ bar listed above. If I am applying for appointment as a nonattorney Mediator, I certify that I am a member in good standing of my profession.

I consent to disclosure of the information contained in this Application to ADRO personnel and to the parties and their representatives whose matters have been referred to the Out-of-court Mediation Program.

I declare under penalty of perjury that the information contained in this Application is true and correct.

Executed on _______ ___, ______ at ___________________, ____________________.

_____________________________________________
Typed or printed name

Return completed application and diskette to:

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________