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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