Northern Virginia Mediation Service ¨ _ Institute For ...
Northern Virginia Mediation Service
Mediator Application
Application Information
This is an application to work with the Northern Virginia Mediation service.
PROFESSIONAL CIVIL MEDIATOR ROSTER
Programs (Please select one or more)
♦ Active Court
or
♦ Auxiliary Court
♦ Commercial
♦ Workplace
♦ Neighborhood (Pro Bono)
Contact Information
____________
Last Name First Middle
__________
Occupation or Career Field
HOME:
____________
Street Address (Including Apt.) City State Zip Code
____________
Telephone Number Email Address
WORK:
____________
Company Name
____________
Street Address (Including Apt.) City State Zip Code
____________
Telephone Number Email Address/Fax Number
(Continued)
Academic Background
With the most recent first, list universities, professional and graduate schools
attended, and any school in which you are currently enrolled.
|Name/Location of |Dates Attended |Major |Degree or No. of Credits |
|Institution | | | |
|(undergraduate and graduate) |From To | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
_
Areas of Industry Experience
Please select those industries, which you have prior experience in professionally, or that you have had experience in with mediation.
Substantive Knowledge
□ Civil Disputes
□ Business
□ Commercial
□ Construction
□ Contract
□ Discrimination
□ Employment
□ Insurance
□ Labor
□ Landlord/Tenant
□ Medical Malpractice*
□ Probate
□ Real Estate
□ Tax
□ Torts
□ Trusts
□ Community Issues
□ Consumer
□ Cross-Cultural
□ Human Rights
□ Regional
□ Environmental
□ Brownfields
□ Hazardous Waste
□ Wetlands
□ Industry
□ Construction
□ Public Utilities
□ Transportation
□ State or Municipal Government
□ Other (please list)
______________________________
Mediator Availability
Please check your geographic, case and time availability and language capabilities:
Location Preference
Please select 1 – 4 from highest preference to least.
____ Fairfax County
____ Arlington County
____ Loudoun County
____ City of Falls Church
Schedule
| |Monday |Tuesday |Wednesday |Thursday |Friday |Saturday |Sunday |
|Morning | | | | | | | |
|Afternoon | | | | | | | |
|Evening | | | | | | | |
(Continued)
Additional Language Fluency
♦Am. Sign Language
♦Spanish
♦Vietnamese
♦Korean
♦Lao
♦Other __________________________________________
Certification or License
Please list current certifications or licenses held.
Virginia Mediator Certification Type (s) Original Date Certified Certification Number
Other License(s) and State or accrediting organization
Mediation Training
Please list completed or planned mediation training.
| |Trainer(s) | | |
|Course Title |Names |Date(s) |Virginia Supreme |
|& | |Attended |Ct. Approved? |
|Training Organization | | | |
| | | | |
| | | |♦ Yes |
| | | |♦ No |
| | | | |
| | | |♦ Yes |
| | | |♦ No |
| | | | |
| | | |♦ Yes |
| | | |♦ No |
(Continued)
Experience Please describe your mediation below or on a separate additional page:
NVMS offers community-based mediation services on a pro bono basis for the first three hours of mediation followed by a sliding scale rate. These cases typically include neighborhood, landlord/tenant, restorative justice, commercial, or contract disputes. Please check the below box and list availability if interested in this opportunity:
Signature Date
Application Requirements:
1) Mediator Application
2) Current Resume
3) CV (optional)
4) GDC Mentee Evaluation Forms
Please email to Community Programs Manager using:
ATT: CIVIL MEDIATOR ROSTER APPLICATION
Email: dbates@nvms.us
Phone: 703.865.7262
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