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522A (Nevada Real Estate Division)

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Please be advised:
Referee applications will only be accepted during the time that
the Division has an open solicitation.
********currently there is no open solicitation********
Revised 4/16/2018 Page 1 of 2 Form 522A
STATE OF NEVADA
DEPARTMENT OF BUSINESS AND INDUSTRY - REAL ESTATE DIVISION
OFFICE OF THE OMBUDSMAN FOR COMMON-INTEREST COMMUNITIES AND CONDOMINIUM HOTELS
3300 West Sahara Avenue, Suite 350 * Las Vegas, NV 89102
(702) 486-4480 * Toll free: (877) 829-9907 * Fax: (702) 486-4520
E-mail: CICOmbudsman@red.nv.gov http://red.nv.gov
ALTERNATIVE DISPUTE RESOLUTION
REFEREE / ARBITRATOR APPLICATION FORM
(Please Print or Type)
Name: ____________________________________________________________________________________
Address: __________________________________________________________________________________
City: ____________________________________ State: _________________ Zip: ______________________
Email address: _____________________________________________________________________________
Daytime number: ______________________ Fax: ______________________ Cell: ______________________
NEVADA BAR ID# _____________________ Current Member Status: _____________________________
Must be in good standing
Current Specialization(s): ____________________________________________________________________
List major area of specialization or subject expertise related to homeowner association knowledge/operation: real
estate, CC&R’s, bylaws, budgets, accounting, injuries, construction, insurance, etc., as well as NRS 116:
__________________________________________________________________________________________
__________________________________________________________________________________________
Qualifications:
List formal training on the hearing of cases/claims and issuance of decisions:
Course/Training Titles: ______________________________________________________________________
Date(s): __________________________________ Number of Hours: _________________________________
Provider Name/Address: _____________________________________________________________________
Completion Validation: ______________________________________________________________________
(Attach additional training if applicable)
PLEASE INDICATE IF YOU WOULD LIKE TO BE CONSIDERED FOR THE ADR MEDIATION PANEL:
☐ Yes, I would like to be considered ☐ No, I do not wish to be considered
PLEASE INDICATE IF YOU WOULD LIKE TO BE CONSIDERED FOR THE ADR ARBITRATION PANEL:
☐ Yes, I would like to be considered ☐ No, I do not wish to be considered
Revised 4/16/2018 Page 2 of 2 Form 522A
Name of Mediation/Arbitration organization or service:
__________________________________________________________________________________________
Address: ____________________________ City: ___________________________ State: _____ Zip: _________
Phone: ______________________________ Member Since: _________________________________________
Please describe any experience with the resolution of homeowner association disputes. If no experience, please enter N/A:
__________________________________________________________________________________________
Geographic Service Area:
☐ Reno/Carson/Tahoe Area
☐ Northeastern Nevada
☐ Central Nevada
☐ Greater Las Vegas Area
Please list foreign languages, or sign language, in which you have sufficient fluency to serve as a neutral:
__________________________________________________________________________________________
Fee and Expenses:
_____________ I acknowledge that my rate will be a maximum of $200 per hour, not to exceed a total of $1,000
per Referee hearing.
_____________ I acknowledge that Mediation proceedings may be subsidized by the Division as per NAC 116.520
in an amount not to exceed $500 or $250 for each party who is eligible for subsidy, whichever is
less.
_____________ I acknowledge that Referee proceedings are subsidized to the extent funds are available.
_____________ Should I be appointed to the ADR Mediation panel, I acknowledge that as per NRS 38.330(2), all
mediations are to be conducted at the maximum rate of $500 for no more than (3) hours. Any
additional mediation time must be agreed upon by all parties involved, and the rate of this additional
time is to be no more $200.00 per hour.
_____________ I CERTIFY that the above information and any other information I am submitting for this
application is true and correct to the best of my knowledge and that I may be removed from the
Referee panel or the approved Division Neutral List for intentionally falsifying the information
provided. False certification may also subject me to civil or criminal penalties. I understand that
all of the information provided is a public record. I agree to comply with all provisions of NRS
Chapter 38.
_____________ If I am listed on the Division Neutral List, I agree to perform resolution services to the best of my
ability in an ethical and proper manner and in accordance with the time provisions of the Referee
process.
______________ I acknowledge that unless otherwise agreed to by the parties, the referee is appointed on a rotating
basis within the discretion of the Division.
________________________________________ __________________________________ _____________
Signature Print Name Date
STATE OF ____________________________ ___ ss. COUNTY OF ____________________________________
I certify that this is a true and correct copy of a document in the possession of ________________________________
PRINT NAME
_________________________ ______ __________________________
Notary Signature Commission Expiration:
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522A (Nevada Real Estate Division)

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Completed 28 December 2021

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