**UNITED STATES DISTRICT COURT**

**Eastern District of New York**

PLEASE REPLY TO:

ROBERT C. HEINEMANN Q BROOKLYN OFFICE

CLERK OF COURT U.S. COURTHOUSE

225 CADMAN PLAZA EAST

BROOKLYN. NY 11201

> Q LONG ISLAND OFFICE
>
> U.S. COURTHOUSE

100 FEDERAL PLAZA

CENTRAL ISLIP, NY 11722

Dear Sir/Madam:

Thank you for your interest in becoming a member of the Court Annexed
Arbitration

Program at the Eastern District of New York. Enclosed/attached is an
application for

certification as arbitrator. Additional information regarding the ADR
program may be found

at [www.nyed.uscourts.gov/adr]{.underline}.

If you have any questions relating to Arbitration, contact the
Arbitration Clerk at

718-613-2325 or email: [rita_credle@nyed.uscourts.gov.]{.underline} For
matters concerning Mediation,

please contact Gerald Lepp at: 718-613-2577 or
[gerald_p_lepp@nyed.uscourts.gov .]{.underline}

Rita Credle

Arbitration Clerk

\(718\) 613-2325

[rita_credle@nyed.uscourts.gov]{.underline}

**APPLICATION FOR CERTIFICATION AS ARBITRATOR**

**FORMAT FOR COURT ANNEXED ARBITRATION**

**U.S. DISTRICT COURT, EASTERN DISTRICT OF NEW YORK**

**225 Cadman Plaza East**

**Brooklyn, New York 11201**

**Web address: [www.nyed.uscourts.gov/adr]{.underline}**

\(1\) Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Office Address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Office Telephone: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Cellular Phone:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Email Address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Home Address
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Home
Telephone:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\(2\) Date Admitted to Practice before:

A\) Appellate Division of the Supreme Court of the State of New York

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

B\) United States District Court, Eastern District of New York

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\(3\) Date admitted to practice before the highest court of a state
other than New York:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\(4\) Set forth briefly in chronological order, with dates, the nature
of your practice

of law since admission to the Bar:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\(5\) Are you presently engaged in the active practice of law in the
Eastern District

of New York? Yes\_\_\_\_\_\_\_ No\_\_\_\_\_\_\_

\(6\) State briefly the nature of your present practice:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\(7\) What percentage of your practice consists of representing:

Plaintiffs\_\_\_\_\_\_\_\_\_\_\_ Defendants \_\_\_\_\_\_\_\_\_\_\_

\(8\) Please list any district judge or U.S. magistrate judge in this
district before

whom you have appeared who otherwise may have knowledge of your

qualifications:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\(9\) If you have not named any judge of this Court in answer to
question no. 8,

please list any other federal judges or state judges before whom you
have

appeared or who may otherwise have knowledge of your qualifications

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\(10\) Have you ever be en disciplined by any Court or Administrative
Office of a

Court? If yes give details. Yes\_\_\_\_\_\_\_\_ No\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\(11\) Please set forth any additional information you believe would
bear upon your

qualifications to serve as an arbitrator. You may attach additional
pages

if necessary:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\(12\) Do you understand the compensation limitations for arbitrators
appointed

under the arbitration Plan and do you agree to accept as full
compensation

payments within those limits? Yes\_\_\_\_\_\_\_ No\_\_\_\_\_\_\_\_

\(13\) If you are certified to be an arbitrator, would you be willing to
hear cases at:

Brooklyn\_\_\_\_\_\_\_\_\_\_ Central Islip\_\_\_\_\_\_\_\_

\(14\) If you are certified as arbitrator, would you be willing on
occasion to serve on

short notice in situations where, for some reason, an arbitrator
previously appointed is unavailable Yes\_\_\_\_\_\_\_\_
No\_\_\_\_\_\_\_\_\_

I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(Signature) Date

Check the Fields of Specialization of your present practice

Admiralty\_\_\_\_\_\_

Business \_\_\_\_\_\_\_ (Specify) \_\_\_\_\_\_\_\_\_\_\_\_\_\_

General Practice \_\_\_\_\_\_\_

Medical Malpractice\_\_\_\_\_\_

Product Liability \_\_\_\_\_\_

Labor \_\_\_\_\_\_\_\_

OTHER: \_\_\_\_\_\_ (Specify) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

The completed application may be sent to:

**U.S. District Court, EDNY**

**225 Cadman Plaza East**

**Brooklyn, New York 11201**

**[Attention: ADR Department]{.underline} :**

**Telephone: 718-613-2577**

**Arbitration Clerk: Brooklyn Office : 718-613-2325**

**Arbitration Clerk: Central Islip Office: 631-712-6047**