STATE OF CALIFORNI A
COURT OF APPEAL, THIRD APPELLATE DISTRICT
APPELLATE MEDIATION PROGRAM—SACRAMENTO
MEDIATOR APPLICATION
(Please attach your résumé and any additional pages required.)
EXCEPT FOR PAGE 4, THE INFORMATION PROVIDED IN THIS APPLICATION IS NOT CONFIDENTIAL
AND MAY BE DISCLOSED TO MEMBERS OF THE PUBLIC.
________________________________________________________________________________________________________________
Name:_______________________________________________________________ State Bar No. _______________
Firm Name (or Agency): ___________________________________________________________________________
___________________________________________________________________________________________________
Office Address (or P.O. Box), City or Town, County and Zip Code
Office Phone: ____________________ Fax: _____________________ E-mail: _____________________________
___________________________________________________________________________________________
1. List your education, including schools, degrees and the dates received.
2. Describe any mediation training you have received. 1 For each training, give the
trainer’s name, the dates attended and the total hours if available.
3. Identify the subject matter of five disputes for which you have been a mediator in the
past five years, with the dates. (Do not give the names of the parties.) State whether
you were a sole mediator or a co-mediator.
(a) _____________________________________________________________________________
_____________________________________________________________________________
(b) _____________________________________________________________________________
_____________________________________________________________________________
(c) _____________________________________________________________________________
_____________________________________________________________________________
(d) _____________________________________________________________________________
1 Previous mediation training is not required.
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_____________________________________________________________________________
(e) _____________________________________________________________________________
_____________________________________________________________________________
4. List other court mediation panels of which you are a member.
____________________________________________________________________________________
5. Identify any other significant mediation experience you have had. 2
____________________________________________________________________________________
____________________________________________________________________________________
6. Check your areas of practice:
Attorney Fees Family Law Personal Injury
Banking/Foreclosure Government Entity Probate
Business Housing Professional Negligence
Civil Rights Insurance Public Entity
Contract Intellectual Property Real Estate
Construction Labor Securities
Defamation Landlord/Tenant Appellate
Eminent Domain Medical Malpractice Other:
Employment Partnership
7. How many years have you been in active practice? _____ If none, please explain.
8. What is or was the nature of your practice?
9. Are you certified in any specialty? If so, please list.
10. What percentage of your practice has been representing:
Plaintiffs: ____% Defendants: ____%
11. Approximately how many of the following have you completed in the past five years?
Jury trials: ___ Court trials: ___ Arbitrations: ___ Appeals: ___ Administrative Proceedings: ___
12. Describe your appellate experience.
2 No prior mediation experience is required.
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13. Is your mediation style facilitative or evaluative/directive?
14. List any languages, other than English, in which you can conduct a mediation.
15. If the parties and you agreed to continue the mediation beyond four hours, what hourly
rate would you charge? Would you consider continuing pro bono? If so, please
explain.
16. State any other information that should be considered in respect to your application.
Please read and sign the following agreement:
A. In consideration of the free appellate mediation training to be provided by the Court of Appeal
(the Court), I agree to accept up to four (4) mediation referrals.
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B. With respect to each mediation that I conduct, I agree to provide up to four (4) hours of
mediation with the parties free of charge. In the event that the parties agree to have me
mediate their dispute beyond four hours, the parties may do so by agreeing to pay me for my
services at my ordinary hourly rate stated above. I acknowledge that in no circumstances shall
the Court be responsible for paying me any fees, by way of direct payment, guarantee or
otherwise. Rather, in the event that I provide services in addition to the four hours of free
services, the parties shall be solely responsible for my fees.
C. I agree to be bound by the Court’s mediation rules and procedures.
D. I agree to waive any and all claims against the Court arising out of my mediation of any Court-
referred dispute. I acknowledge that I am an independent contractor and that I serve as a
mediator at the will of the Court. The Court may terminate my services as mediator at any time
for any reason.
E. I agree to adhere to the Alternative Dispute Resolution Rules for Civil Cases as set forth in the
California Rules of Court.
Date: ________________________ Name: _____________________________________
(print)
______________________________________
(signature)
MAIL OR FAX THIS APPLICATION WITH YOUR RÉSUMÉ AND ANY OTHER ATTACHMENTS TO:
Rene Ackerman, Administrator to the Mediation Program TEL: (916) 643-7084
COURT OF APPEAL, THIRD APPELLATE DISTRICT FAX: (916) 641-6527
2890 Gateway Oaks Drive, Suite 210
Sacramento, California 95833 EMAIL: [email protected]
THE APPLICATION SUBMISSION DEADLINE IS February 14, 2020.
3 The mediation training will take place in Sacramento during the last quarter of the fiscal year (April, May, June 2020) with
the final dates to be announced after the bidding and contracting process is completed.
(a fillable version of this form is located online at: http://www.courtinfo.ca.gov/courts/courtsofappeal/3rddistrict/documents/mediator_application.pdf)
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*********************THIS PAGE IS CONFIDENTIAL AND FOR COURT USE ONLY*********************
Name:_______________________________________________________________ State Bar No. _______________
R EFERENCES
List the names and telephone numbers of three persons familiar with your mediation (M) or
appellate (A) skills, indicating which applies:
Name Phone M A
Print Form -4- Clear Form
