Application Form

Please select the listing option you are interested in below. *

First Name *

Middle Initial

Last Name *

Work Address *

Suite #

City *

State *

Zip Code *

Work Telephone Number *

Work Email Address *

Current Employment:

Beginning Date *

Name of Employer *

Street Address *

City *

State *

Zip Code *

Are you currently affiliated with any mediation/arbitration services? *

Yes

No

If YES, please list the name, location, and position held with each mediation/arbitration provider:

	Name	Address, City, State	Position
-	Name	Address, City, State	Position
-	Name	Address, City, State	Position
-	Name	Address, City, State	Position
-	Name	Address, City, State	Position

Background Information

Have you ever been convicted, found guilty, or pled guilty or nolo contendere (no contest) to a felony under the laws of any municipality, county, state, territory or country, whether or not adjudication was withheld or a judgment of conviction was entered? *

Yes

No

Have you ever been named in an administrative proceeding/action by any state agency or public authority or any other regulatory authority? (This would include fines, probation, restitution, restricted or probationary licenses, cease and desist orders, suspension, revocation, or denial.) *

Yes

No

Have you ever been subject to any civil, criminal, or administrative action for a violation of the Florida Rules for Certified and Court-Appointed Mediators, or aiding, instructing, or encouraging another party in committing such a violation? *

Yes

No

Please provide one professional reference below. *

	Name	Job Title	Company	Email	Phone Number	Address
-	Name	Job Title	Company	Email	Phone Number	Address

Requirements for Qualifying

Do you possess an active certification as a Certified Mediator? *

Yes

No

Are you a Qualified Arbitrator? *

Yes

No

If YES, please list the type of ADR certification/qualification you hold, and the date(s) of that certification/qualification: *

	Type	State
-	Type	State
-	Type	State
-	Type	State
-	Type	State

Please attach your resume or CV below. *

Signature of Applicant *

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