Approved, SCAO

CIVIL MEDIATOR APPLICATION

To be eligible to serve as a general civil mediator, you must meet the training and experience criteria specified either in
MCR 2.411(F)(2) or in the SCAO Mediation Training Standards and Procedures pursuant to MCR 2.411(F)(3).

Service as a case evaluator under MCR 2.403 does not constitute a qualification for serving as a mediator.   Refer to the Mediation Training
Standards and Procedures for further information about minimum qualifications.

Note:  Except for Part B, the information provided in this application is available to the public for inspection.

Please type or print neatly.

1. Full name (first, middle initial, last)

3. Address  where  you  can  be  contacted

2. Bar no. if applicable
P

4. Telephone no.
(       )

5.  Fax no.
(       )

6. E-mail address

Part A:  General Civil Mediator Qualifications  Complete item 7 and either item 8, 9, or 10 as appropriate.

7.

Is this a

new application?

renewal?  Contact the local court for renewal requirements before submitting this application.

8. Qualification through State Court Administrative Office (SCAO)  Approved Training

.    Attach  copy  of  certificate.

a. SCAO-approved training completed on

Date

Trainer:

b.

Juris doctorate.   Attach copy of diploma if not a licensed attorney.

Graduate degree in conflict resolution.   Attach copy of diploma.

40 hours of mediation experience in the past 2 years.  Detail below.  Complete on separate page if needed.

c. Observed two general civil mediation proceedings.   Specify dates and mediator names and attach verification.  Do not provide party names.

d. Conducted one general civil mediation to conclusion.  Specify date and name of mediator serving as supervisor and attach verification.  Do

not provide party names.

9. Qualification by Community Dispute Resolution Program (CDRP) Training

a. Michigan CDRP training completed on

     .   Attach copy of certificate.

Date

Trainer:

If the training was completed more than 2 years before applying, applicant must have completed 8 hours of advance mediation
training in the 2 years before applying.  Specify type of training, dates, and trainers, and attach copy of certificate.

continued on page 2

MC 281a   (3/13)   CIVIL MEDIATOR APPLICATION, Page 1 of 3

MCR 2.411(E)

Civil Mediator Application, continued from page 1

Part A:  General Civil Mediator Qualifications (continued)

9.

b. Observed two general civil mediation proceedings.   Specify dates and mediator names and attach verification.  Do not provide party names.

c. Conducted one general civil mediation to conclusion.  Specify date and name of mediator serving as supervisor and attach verification.  Do

not provide party names.

d.

If not an attorney or a person holding a juris doctorate or graduate degree in conflict resolution, mediation, or comediation,
applicant must have mediated at least 40 hours or 18 cases in the 2 years before applying.  Detail below.  Complete on separate page
if needed.  Do not provide party names.

10. Qualification by Training Outside of Michigan

a. Completed a comprehensive training course of at least 40 hours designed for general civil case mediation.  Attached are:

(1) a certificate of completed training, (2) a copy of the training agenda, (3) the name of the trainer, and (4) the dates of attendance.

b.

If the training was completed more than 2 years before applying, applicant must have completed at least 8 hours of advanced
mediation training in the 2 years before applying.  Specify type of training, dates, and trainers, and attach copy of certificate.

c. Observed two general civil mediation proceedings.   Specify dates and mediator names and attach verification.  Do not provide party names.

d. Conducted one general civil mediation to conclusion.  Specify date and name of mediator serving as supervisor and attach verification.  Do

not provide party names.

e.

If not an attorney or a person holding a juris doctorate or graduate degree in conflict resolution, mediation, or comediation,
applicant must have mediated at least 40 hours or 18 cases in the 2 years before applying.  Detail below.  Complete on separate page
if needed.  Do not provide party names.

CERTIFICATION

I certify that I: (a)  meet the requirements for service under the court's mediator selection plan; (b) will not discriminate against parties

or attorneys on the basis of race, ethnic origin, gender, or other protected personal characteristic; and (c) will comply with the court's

ADR plan, orders of the court regarding cases submitted to mediation, and the standards of conduct adopted by the State Court

Administrator.  My hourly fee is $

.

Date

Signature

MC 281a   (3/13)   CIVIL MEDIATOR APPLICATION, Page 2 of 3

MCR 2.411(E)

Civil Mediator Application - gender and race information to be maintained separately from pages 1 and 2 of application

Full name (first, middle initial, last) (print or type)

Bar no. (if applicable)
P

Providing the following information is optional.   It is requested in accordance with MCR 2.411(E)(1)(c) and will be maintained separately
from your application.

Part B:  Gender and Race Information

Check the boxes that apply to you.

Gender:

Female

Male

Race/Ethnicity:

American Indian or Alaskan Native

Asian or Pacific Islander

Black/African American (non-Hispanic)

Hispanic

White/Caucasian (non-Hispanic)

Other (specify):

Part C:  Observer Information and Pro Bono Services

Providing the following information is optional and will be maintained separately from your application.

1. Once you have been qualified by the court to serve as a mediator:

a. Are you willing to be observed by a prospective mediator?

b. Are you willing to observe a prospective mediator in mediation pro bono?

2.

Are you willing to accept appointment from the court to serve as a pro bono
mediator once a year?

Yes

Yes

Yes

No

No

No

MC 281a   (3/13)   CIVIL MEDIATOR APPLICATION, Page 3 of 3

MCR 2.411(E)