UNITED STATES DISTRICT COURT

NORTHERN DISTRICT OF CALIFORNIA

ADR NEUTRAL APPLICATION

Application for (check one or more):  MEDIATOR  ENE EVALUATOR 
ARBITRATOR

*Please complete the entire application, using additional paper if
necessary.*

Name:

Firm or Office Name:

Office Address:

Office Phone: Office Fax:

E-mail address: Website:

**ADR EXPERIENCE**

Summarize ADR experience, particularly in the last five years:

Other courts or organizations for which you serve as an ADR neutral:

Number of sessions conducted as an ADR neutral:

Mediation: ENE: Arbitration: Other, specify (*e.g.* judge *pro tem*,
settlement
conference):\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**ADR TRAINING**

**Course** **Course** **No. of Hours Role-playing**

**[Provider]{.underline} [Content]{.underline} [Date]{.underline} [by
Participants ]{.underline}**

**PRACTICE AREAS**

For each ADR panel to which you are applying, please check all subject
areas in which you believe you are qualified to serve. Note that ENE and
Arbitration require greater substantive expertise than Mediation because
Evaluators prepare evaluations and Arbitrators render awards on the
merits of the case.

  --------- --------- --------- ----------------------- -- --------- --------- --------- --------------------------
  **ENE**   **MED**   **ARB**   **Subject Area**           **ENE**   **MED**   **ARB**   **Subject Area**

                                Administrative /                                         International Law
                                Regulatory                                               

                                Antitrust                                                Labor Relations

                                Aviation                                                 Land Use/Zoning

                                Banking/Financial                                        Landlord/Tenant
                                Services                                                 

                                Bankruptcy                                               Legal Malpractice

                                Business Torts                                           Libel/Slander

                                Constitutional Law                                       Medical Malpractice
                                General                                                  

                                Constitutional-First                                     Maritime-Personal Injury
                                Amendment                                                

                                Construction                                             Maritime-Cargo

                                Consumer                                                 Oil & Gas

                                Contracts                                                Partnerships

                                Copyright-General                                        Patent-Biotech/Medical

                                Copyright-Information                                    Patent-Chemical
                                Technology                                               

                                Debtor/Creditor                                          Patent-Computer/Software

                                Disability: Access                                       Patent-Electrical

                                Disability: Education                                    Patent-Mechanical

                                Disability: Employment                                   Personal Injury

                                Education                                                Police Misconduct

                                Elections                                                Prisoner Civil Rights

                                Eminent Domain /                                         Product Liability
                                Condemnation                                             

                                Employment                                               Qui Tam
                                Discrimination                                           

                                Environmental                                            Railroad

                                ERISA                                                    Securities

                                Franchise                                                Sexual Harassment

                                Fraud                                                    Tax

                                Government-Contracts                                     Trade Secrets

                                Government-Public                                        Trademark
                                Agency Law                                               

                                Health Care                                              UCC

                                Housing Discrimination                                   Unfair Competition

                                ICC                                                      Utilities

                                Immigration                                              Wrongful Termination
  --------- --------- --------- ----------------------- -- --------- --------- --------- --------------------------

**LEGAL AND OTHER PROFESSIONAL EXPERIENCE**

Summarize legal or other professional experience (including teaching),
particularly in the past five years.

**Attorney Applicants Only**

**[Nature of Practice]{.underline}**

> \_\_\_\_\_\_\_ Litigation: Number of years in active litigation
>
> Percentage of practice in last 5 years:
>
> representing plaintiffs: % in federal court: %
>
> representing defendants: [\_\_\_\_]{.underline}% in state court: %

\_\_\_\_\_\_\_ Transactional

> \_\_\_\_\_\_\_ Other

**[Bar Admissions]{.underline}**

  ----------------------------- -------------------- --------------------
  Bar                           Bar No.              Year of Admission

  Northern District of          n.a.                 
  California:                                        

  California Bar                                     

  Others: *specify*                                  
  ----------------------------- -------------------- --------------------

**LEGAL AND OTHER PROFESSIONAL EDUCATION**

**Degree School Year Received**

**OTHER RELEVANT INFORMATION**

Other relevant information (e.g. publications, professional
affiliations, awards, additional experience or skills)

**SERVING AS A NEUTRAL**

*Mediator and ENE Evaluator Applicants only:*

Number of court cases per year for which you are willing to serve as a
neutral (the minimum is 3 cases per program)

Mediation cases: ENE cases: \_\_\_\_\_\_

Preference for type of cases you would like to be assigned:

Locations in which you are available to conduct ADR sessions:

  ----------------- ----------------- ----------------- -----------------
   San Francisco    San Jose         Oakland          Marin County

   Palo Alto        Monterey         Walnut Creek     Santa Rosa
  ----------------- ----------------- ----------------- -----------------

 Other *specify*:

**I consent to public disclosure, including on the court=s internet
site, of the information above.**

 **yes**  **no**

*(The court will post your profile only if you are an existing neutral
or if you are accepted to an ADR panel.***)**

***This section will not be made publicly available.***

References (if possible, include lawyers or parties in ADR sessions you
conducted):

**[Name]{.underline} [Phone No.]{.underline} [Context in which reference
knows you]{.underline}**

Have you ever:

\(1\) been part of any civil, criminal or administrative proceeding
charging you with conduct involving dishonesty, unethical conduct or
commission of a crime? or

\(2\) been disciplined or cited for a breach of ethics or unprofessional
conduct by any court, administrative agency, bar association, or other
professional group, excluding sanctions in an amount less than \$1000,
imposed against you in a civil proceeding? [\_\_\_\_]{.underline} **yes
\_\_\_\_\_\_ no** (*if yes, please attach a declaration*)

I certify that all the foregoing information is true and correct.

Date:

Signature

**PLEASE RETURN COMPLETED APPLICATION TO:**

**ADR Unit**

**U.S. District Court**

**450 Golden Gate Ave.**

**San Francisco, CA 94102**

**(415) 522-2199 FAX: (415) 522-4112**

**Email: [ADR@cand.uscourts.gov]{.underline}**

REV.8/08