Application for Mediator Certification (p. 1) (Rev. 2/24 ...

Application for Mediator Certification (p. 1) (Rev. 2/24/17)

SOUTH CAROLINA BOARD OF ARBITRATOR AND MEDIATOR CERTIFICATION

Full Name of Applicant Mr. Ms. Mrs.

Firm or office name

APPLICATION FORMEDIATOR CERTIFICATION

Mailing Address

Date of Birth

City

State

Zip

County

Telephone No.

Fax No.

E-Mail Address

Web Address

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Check one, and provide required informatIio. nA: DMISSIONS AND AFFILIATIONS

Ch1e.ckIownaes, aanddmpitrtoevdidtoe prerqacutiirceedlianwfoirnmSaotuiotnh:Carolina on _________________________ (must be admitted at least 3 years); am a member in good standing of the South Carolina Bar (my SC Bar No. is _________); and, I have not, within the last

1. fIiwveasyeaadrms, ibtteeedntdoispbraarcrteicdeolar wsuisnpSeonudtehdCfraoromlinthaeopnra_c_t_i_ce__o_f_la_w__, _b_e_e_n_d_e_n__ie_d__a_d_m(imssuiosnt btoe aadbmaritftoerd at least 3 years); cahmaraamcteermobreertihnicgaol oredasstoannsdoinrgbeoefnthpeuSboliuctlyhrCeaprroimlinaanBdaerd(morypSuCblBicalryNdois.cisip_l_in_e_d__fo_r_p_)r;oafnedss,iIohnaavleconnodt,uwcitt;hoirn the last five years, been disbarred or suspended from the practice of law, been denied admission to a bar for

character or ethical reasons or been publicly reprimanded or publicly disciplined for professional conduct; or 2. I am admitted to practice law in the highest court of another state or the District of Columbia for at least 3 years:

(Attach Certificate of Good Standing from each jurisdiction.) 2. I am admitted to practice law in the highest court of another state or the District of Columbia for at least 3 years:

C(AotutratcshinCwerhtiicfihcaatdemoitftGedootodpSrtaacntidcieng fromDaetaec(sh) joufraisddmicistisoionn.)

Bar No(s).

______________________________ _C_o_u_r_ts_i_n__w_h_i_ch__a_d_m__it_t_e_d_t_o_p__ra_c_t_ic_e ______________________________

__________________ _D_a_te_(_s_)_o_f_a_d_m__is_s_io_n__ __________________

________________ _B_a_r _N_o_(_s_).________ ; and ________________

I_a_m___a_t _le_a_s_t_2_1__ye_a_r_s_o_l_d_;_a_n_d_,_____

__________________

________________ ; and

II hamaveatrelecaesitve2d1 ayejuarrsisodldo;catonrda,te degree or its equivalent from this law school approved by the American

Bar Association or the Supreme Court under Rule 402(c)(3), SCACR:

LI ahwavSecrheocoeilved a juris doctorate degree or iDtseegqrueeivalent from this law school approvedDbaytethe American

_B_a_r _A_s_so__ci_a_t_io_n__o_r_t_h_e_S_u_p_r_e_m__e_C_o_u__rt unde_r_R_u_le__4_0_2_(_c)_(_3_),_S_C_A_C_R__: _____________ ____________; and,

Law School

Degree

Date

I_a_m___a_m__e_m_b_e_r__in__g_o_o_d__st_a_n_d_i_n_g_i_n_e_ach jur_i_sd_i_c_ti_o_n__w_h_e_r_e_I_a_m__a_d_m__i_tt_e_d__to__p_ra_c_t_ice la_w__; _a_n_d_, _____; and,

II hamavea nmoetm, wbitehriinntghoeoldassttfaivnediynegarins, beaecehn jduirsibsdaircrteidonorwshuesrpeeInadmedafdrmomitttehdetporpacraticcteicoefllaaww;,abnede,n denied admission to a bar for character or ethical reasons or been publicly reprimanded or publicly disciplined for professional conduct; and, I have not, within the last five years, been disbarred or suspended from the practice of law, been denied admission to IaabmarafnoracshsoacraiactteermoermetbheircaolfrtehaesoSnosuothr bCeaeronlipnuabBlaicrlyinregporoimd astnadneddinogr (pSuCbBliacrlyNdoi.s_c_ip_l_in_e_d__fo_r__p_ro_f_e_s_s)io; annadl ,conduct; and,

II aaggmrreeaeenttaoossbboeecssiauutbbejjeemccett mttoobttehhreeoRRfuuthlleeess SoooffuPPtrrhooffCeeassssroiioolinnnaaall BCCaoornniddnuugccott,,oRRduuslleeta44n00d77i,,nSSgCC(AASCCCRRBaaannr ddNotthh. _ee_RR_uu_ll_ee_oo_nn_________); and,

DCDCIDaaaiiisssgrrcccooriiiellpppiiennllliiiaannntoaaaBBrrrbaayyyrre..PPPsrrruooobccceeejedddcuuutrrrteeeo,,,

RRthuuelleeR44u11l33es,, SSoCCfAAPCCroRRf,,ettoossttiohhneeasslaaCmmoeendeeuxxttceetnn, Rttuaalsseaa4nn07aa,ccSttiiCvvAeeCmmReeammnbbdeetrrhooeffRttuhhleeeSSooonuutthh Rule 413, SCACR, to the same extent as an active member of the South

Carolina Bar.

3. ___ I am applying for certification as a Circuit Court Mediator ___ I am applying for certification as a Family Court Mediator (check all that apply)

AApplication ID: _______________ (For Board use only)

A

AApppplliiccaattiioonn ffoorr CMirecduiiat tCooruCrteMrtiefidciaattioornC(epr.ti2fi)ca(Rtioenv.(p2./22)4(/R1e7v). 2/28/03) II. LEGAL EXPERIENCE

Experience in active litigation: _______ years _______ months Summarize legal experience (including teaching) since admission to the bar, particularly in the past five years: ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________

III. MEDIATION AND OTHER PROFESSIONAL EXPERIENCE

Mediation experience: ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________

Membership and positions held in bar, alternative dispute resolution (ADR) and professional associations:

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

Number of mediations conducted as neutral: ________________ .

Number of mediations attended: ______ .

IV. MEDIATION TRAINING 1. I am familiar with the statutes, rules and practice governing mediated settlement conferences in South Carolina.

2. I am familiar with the South Carolina Standards of Conduct for Mediators

3.

(a) I have completed aminimum of 40 hours in a mediation training program approved by the South

Carolina Board of Arbitrator and Mediator Certification. SSeeeeCSi.rCcu.iCt Coouurtr-tAAnDnRexReudlesA1D3RaRnudle1s4.1(9Atatnadch2a0.co(Apyttoafcyhouar

copcyeortfifyicoauterocfecrotmifpiclaettieonoof rcootmheprlpertoioonf oof rtroaitnhinegr apnrdoodfesocfribtreahinerien.g) and describe here.)

Program Title (Be exact)

Date Started and Completed

Sponsor/Training Conducted By

or

(b) I have completed the following mediation training which has not been approved previously by the Board, or

was attended in another state or was attended prior to January 31, 1995:

Course Provider

Course Content

Date

Place

No. of Hours

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

To demonstrate that this training substantially complies with the standards set forth in Rule 149,, I submit with this application:

a. a detailed agenda for the course, including length of time spent on each subject; b. a list of instructors, including their qualifications and/or vita; c. a certificate of completion or other proof of training; and d. current contact information for the sponsor of the training. By signing and submitting this application, I authorize the sponsor to release to the Board and South Carolina Bar any information regarding this course and my attendance that the Board or Bar might request with respect to this application, and agree to supplement this application as requested.

4. Other mediation or ADR training:

Course Provider

Course Content

Date

Place

No. of Hours

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

Application for CMirecduiat tCooruCrteMrtiefidciaattioornC(epr.ti3fi)ca(Rtioenv.(p2./32)4(/R1e7v). 2/28/03) V. CHARACTER

1. AUTHORIZATION AND RELEASE

I hereby authorize and request that the South Carolina Bar, South Carolina Commission on Lawyer Conduct, South Carolina Commission on Judicial Conduct, South Carolina Bar Admissions Office, and/or the bar admissions and disciplinary agencies of this or any other state, provide to the South Carolina Board of Arbitrator and Mediator Certification or South Carolina Bar information regarding the status of any license to practice law that I hold, including all applications filed by me or complaints filed against me.

Applicant's SC Bar No. ____________________________________

If licensed to practice law in other states, completee tthhee ffoolllloowwiinngg: and attach a Certificate of Good Standing from

eStaacthejurisNdaimctieoonf: Disciplinary and Admissions Agencies

Address

Telephone No. Attorney's ID No.

S_t_a_t_e____N_a_m__e_o_f_D__is_c_ip_l_in_a_r_y_a_n__d_A_d_m__i_ss_i_o_n_s_A_g_e_n__ci_e_s_______A_d_d_r_e_s_s____________T_e_le_p_h__o_n_e_N__o_. _____A_tt_o_r_n_e_y_'s_I_D__N_o_. __________________________________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________

VI. AVAILABILITY

NOTE: All applicants must be on the roster in at least one county.

1. INDICATE COUNTIES IN WHICH YOU WISH TO BE PLACED ON THE COURT ROSTER:

All counties.

Select counties: (mark all that apply)

Abbeville Aiken Allendale Anderson Bamberg Barnwell Beaufort Berkeley Calhoun Charleston Cherokee Chester Chesterfield Clarendon Colleton Darlington Dillon Dorchester Edgefield Fairfield Florence Georgetown Greenville

Greenwood Hampton Horry Jasper Kershaw Lancaster Laurens Lee Lexington Marion Marlboro McCormick Newberry Oconee Orangeburg Pickens Richland Saluda Spartanburg Sumter Union Williamsburg York

Application for CMirecduiat tCooruCrteMrtiefidciaattioornC(epr.ti4fi)ca(Rtioenv.(p2./42)4(/R1e7v). 2/28/03) VII. OTHER INFORMATION

Other relevant experience or skills or other information you would like considered in connection with this application: ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________

VIII. CERTIFICATION

I certify that I am of good moral character; that I am familiar with the statutes, rules and practice governing mediated settlement conferences in South Carolina; and that I have not, within the last five years, been disbarred or suspended from the practice of law, been denied admission to a bar for character or ethical reasons or been publicly reprimanded or publicly disciplined for professional conduct in this state, any other state or the District of Columbia; and I agree to: (1) provide mediation to indigents without pay; (2) notify the Board of any change in the above facts or otherwise in my ability to perform duties as a mediator; and (3) pay all administrative fees and comply with all procedures established by the Supreme Court, or its designee, including the Standards of Conduct for Mediators (Appendix AB u.itCCoouurrtt-AAnDnReRxuedlesA).DIRfuRruthlesr)c.eIrftuifryththeart ctheertinfyfotrhmaat ttihone IinhfaovremfautrinoinshIedhainvethfiusranpisphliecdatinonthisistraupep, alicccautrioatneiasntdruceo,mapccleutrea;taendantdhact,osmhopuleldteI;baenadptphroatv,esdh, tohuisldinIfobreampaptiroonvemda,ythbies uinsefodrmtoagtieonnermataeyabroesutesreodftnoeugternalesrmataedae raovsatielarbolef ntoeuthteraclsoumrtasd, AeDaRvaciolambmleutnoittyhaencdoguertnse,rAalDpRubcloicm. munity and general public.

SWORN AND SUBSCRIBED TO BEFORE ME Date

Signature of Applicant

Date

Signature

Title Of Person Authorized To Administer Oaths

SEAL Date Commission Expires

Administratively Approved Signature

IX. FOR BOARD USE ONLY

Date

Referred to Board

Signature

Date

Board approved

Signature

Date

Board contingencies to approval met

Signature

Date

Board rejected

Signature

Date

Additional information requested from applicant Signature

__Discipline check __Application fee paid

__Proof of training __Approved course __At least one county selected

Date __Application signed/notarized

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