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APPLICATION FOR CERTIFICATION (Administrative Office of the Courts)

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Rev. 2019/12/02
APPLICATION FOR CERTIFICATION
ROSTER OF CERTIFIED MEDIATORS
FOR ARKANSAS CIRCUIT COURTS
This application is to be completed by persons who wish to be eligible to serve as compensated
mediators for Arkansas Circuit Courts. Act 1179 of 2003 (codified at Ark. Code Ann. § 16-7-202)
gives circuit and appellate court judges the discretionary authority to order any civil, juvenile,
probate or domestic relations case to mediation.
Pursuant to Ark. Code Ann. § 16-7-104, the Arkansas Alternative Dispute Resolution
Commission is responsible for the certification, professional conduct, discipline, and training of
persons eligible and qualified to serve as compensated mediators for the courts. Certification
by the Commission is required to mediate court ordered cases in Arkansas Circuit Courts,
unless the court authorizes the party’s selection of a non-certified mediator.
In order to be granted certification by the Commission, applicants must meet the standards set
forth in the Commission’s Requirements for the Certification of Mediators for Circuit Courts.
Applications for certification will be reviewed as they are received. You will be notified of your
certification status once all information has been verified and the background checks have been
completed. No one should hold himself or herself out as a certified mediator until the
Commission grants the applicant of such status.
Your application will not be processed without all required materials. Included in the
required materials are an Authorization and Release Form, Arkansas State Police Individual
Record Check Form, and Arkansas Child Maltreatment Registry Check Form.
In the event there is an issue with an applicant’s background checks, standing with another
licensing entity, or anything falling under “good moral conduct,” the application is flagged as
discretionary and will be reviewed by the full Commission. If you believe your application will be
discretionary, you may want to contact Commission staff prior to submission.
Certification must be renewed annually. The deadline for renewal is August 31
st
of each year.
To renew certification all mediators must submit a certification renewal form, provide proof of
completion of 6 hours of continuing mediation education credits for the reporting period, and pay
a $75 renewal fee.
Certified mediators are required to maintain statistical information on all court ordered cases
mediated. The form is available on the Commission’s website at
https://www.arcourts.gov/administration/adr/certified-mediators
Rev. 2019/12/02
APPLICATION CHECKLIST
The Arkansas Alternative Dispute Resolution Commission does not accept incomplete
applications. Incomplete applications will be returned to the applicants without
processing.
Documentation of Training
All applicants must provide proof of training from a Commission approved course.
- Training Certificate
- Letter of completion
- Certified letter or copy of transcript from law school or university
Documentation of Degree
– Certified copy of transcript
– Attorneys licensed in Arkansas need only provide their Arkansas Bar number
Documentation of Observations/ Co-mediations/ Mediations
– You must complete two observations, co-mediations, or mediations for each type of
certification for which you have applied.
– Observations, co-mediations or mediations will only be accepted if they were done after
completion of training requirements.
– Documentation may include the observation form, a redacted agreement to mediate,
memo from attorney or party verifying you mediated, or other written verification.
Certification/Background Check Fee of $75.00
– Make check or money order (no cash or credit cards) payable to the
Arkansas. Please ensure your check is signed & dated.
Arkansas State Police Background Check Release Form
– Must be signed by applicant and notarized.
Please include Race, Sex, Driver’s License #, and State of issuance.
Arkansas Child Maltreatment Registry Check Form
– Must be signed by applicant and notarized.
Please ensure the form is signed by applicant and notary.
Authorization and Release Form
Signature of Applicant
APPLICATION FOR CERTIFICATION
Roster of Certified Mediators for Circuit Courts
PART III: P
ERSONAL INFORMATION
The name, address and telephone number of all certified mediators are posted to the ADR Commission’s website:
https://www.arcourts.gov/administration/adr/certified-mediators
1. Name: _____________________________________________________________________________
Last First Middle
______________________________________________________________________________
Organization or Business
2. Mailing Address:
_______________________________________________________________
Street
_______________________________________________________________
City State Zip Code
3. Telephone number:
_______________________________________________________________
4. Fax number: _______________________________________________________________
5.
Email: _______________________________________________________________
6. Date of Birth:
_______________________________________________________________
PART I: I
NDICATE THE CATEGORIES OF
C
ERTIFICATION FOR WHICH
YOU ARE APPLYING
CIVIL PROBATE
DOMESTIC RELATIONS JUVENILE
PART II: T
EMPORARY
OR
E
XPEDITED
C
ERTIFICATION
Applicants must provide documentation verifying eligibility for the follow:
I am applying for temporary certification because:
I am an active duty military service member stationed in the State of Arkansas.
I am a military veteran applying within one year of discharge from active duty.
I am the spouse of an active duty military service member or military veteran.
I am applying for certification and request the Commission expedite the process because:
I am an active duty military service member stationed in the State of Arkansas.
I am a military veteran applying within one year of discharge from active duty.
I am the spouse of an active duty military service member or military veteran.
PART IV: TRAINING
Attach copies of certificates, letters, or transcripts confirming completion of each course.
A. Record of Basic or Civil Mediation Training
Course Name:
____________________________________________________________________
Trainer/Provider: ____________________________________________________________________
Training Location: ____________________________________________________________________
Dates Attended: _______________________________Credit Hours: ________________________
B. Record of Family Mediation Training
(if applicable)
Type of Mediation: ____________________________________________________________________
Trainer/Provider: ____________________________________________________________________
Training Location: ____________________________________________________________________
Dates Attended: _______________________________Credit Hours: ________________________
C. Record of Juvenile Mediation Training (if applicable)
Course Name: ____________________________________________________________________
Trainer/Provider: ____________________________________________________________________
Training Location: ____________________________________________________________________
Dates Attended: _______________________________Credit Hours: ________________________
PART V: EDUCATION
1. List Colleges and universities attended and attach certified transcripts. If you are an attorney
licensed by the Arkansas Supreme Court you are not required to submit transcripts.
School Name:
_______________________________________________________________________
Degree: _____________________ ________ Year Degree Completed:_______________________
School Name:
_______________________________________________________________________
Degree: ____________________________________Year Degree Completed:_____________________________
3. For applicants who wish to apply based on experience in the field of mediation, attach
documentation of your experience with an explanation of how you have substantial, demonstrated,
and satisfactory knowledge, skills, abilities, and experience as a mediator in the applicable field of
mediation.
4. If you have not attained a master’s degree or higher, and are applying for certification in the
domestic relations division, attach documentation of at least two years work experience in family
and marriage issues. If applying for certification in the juvenile division, attach documentation of at
least two years work experience in family and juvenile issues.
PART VI: PRACTICAL EXPERIENCE
Attach Verification of Observation forms completed by each mediator with whom you observed or
with whom you co-mediated attesting to your observations or co-mediations. For mediations you
conducted, attach a copy of the Agreement to Mediate or a memo from one of the participants
attesting that you mediated, the date of the mediation, and the type of case.
Please note that cases mediated in Arkansas District Court or Federal Court do not satisfy this
requirement.
PART VII: OCCUPATION AND WORK EXPERIENCE
1. What is/was your primary occupation?
_________________________________________________
2.. Please list all professional affiliations which you consider relevant to your application.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
PART VIII: ADDITIONAL INFORMATION
1. What language(s), other than English, do you speak fluently (Please include American Sign
Language)?
____________________________________________________________________________________________
____________________________________________________________________________________________
2.
What is your customary hourly fee? ________________________________________________________
Sliding Scale Available
Travel Reimbursement Required
Pro bono mediation
�
No
�
Yes
2. Have you ever applied and been rejected by any board for a certification, licensure, or
registration?
�
No
�
Yes
violations resulting in suspension or revocation of a driver’s license and DWI/DUI offenses.
Have you been convicted of or pled guilty to a violation of the law? This includes disclosing traffic
1.
information.
Also see the
Addendum to the Application for the Certification of Mediators
for additional
If you answer yes to any of the following, attach documentation fully explaining the circumstances.
There will be a $30 service charge for any returned check
ADR Commission.
The application fee is $75.
Please make your check or money order payable to the
Arkansas
PART
X:
FEES
�
No
�
Yes
ave you relinquished a professional privilege or license while under investigation?5.H
�
No
�
Yes
ave your professional privileges been curtailed at any
time?4.H
�
No
�
Yes
Have you been disciplined by any professional organization
or licensing entity?3.
PART
IX:
BACKGROUND
INFORMATION
Return completed application, supporting documents, and fee to:
Arkansas ADR Commission
625 Marshall Street
Little Rock, AR 72201
Phone: (501) 682-9400 Fax: (501) 682-9410
Web: http://arcourts.gov/administration/adr
Signature of Applicant
Date
___________________________________________
_______________________
for purposes of fulfilling my obligation to comply
with the Commission’s Guidelines.
jurisdiction of the courts of Arkansas and the Arkansas Alternative Dispute Resolution Commission
should I be disciplined by any governing body of an applicable agency. I agree to submit to the
I agree to notify the Commission promptly should any professional license I hold be revoked, or
the courts.
my certification to ensure that Client Evaluation forms are provided to all of my clients referred from
to the ADR Commission on an annual basis. I also understand that I am obligated as a condition of
In addition, I understand that to gain and maintain certification I must provide statistical information
by the Arkansas ADR Commission and
all subsequent amendments.
this application for certification is approved, I agree to abide by
the policies and regulations set forth
understand the Commission’s
Requirements for the Certification of Mediators for Circuit Courts.
If
do swear or affirm that I will abide by those standards. Furthermore, I certify that I
have read and
I certify that I have read the enclosed
Requirements for the Conduct of Mediation and Mediators
and
discovered.
the application process, is the basis for
denial, restriction
or loss of certification, whenever
I understand and agree that falsification or material omission of information on this application, or in
results of such an investigation will be used only in considering my suitability for Certification.
Commission to perform an individual background check with law enforcement authorities.
The
I understand that by completing this application I am giving my permission to the Arkansas ADR
herein is subject to verification.
I qualify for the category of certification for which I have applied.
I understand that all information
I certify that the information supplied in this application is accurate, that to the best of my knowledge
PART
XI:
ASSURANCES
STATE Name of Licensing/Disciplinary Body
Address and Phone Number
ID#
Other Applicants: I hereby authorize the licensing or disciplinary agency(s) listed below, to
provide to the Arkansas ADR Commission information regarding the status of my license and all
disciplinary complaints ever filed against me, including those administratively dismissed by such
agency or resulting in non-public discipline.
Arkansas Professional License/Certification/Registration #
___________________________
List name, address, and phone number of the Arkansas licensing agency:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
If licensed in other states, please complete the following:
STATE Name of Licensing/Disciplinary Agency
Address and Phone Number
ID#
_________________________________________ ________________________________
Signature of Applicant Date
If licensed to practice law in other states, please complete the following:
Arkansas Attorney License #
________________________________________________
dismissed by the Board or any other agency, and those resulting in non-public discipline.
information on all disciplinary complaints filed against me, including those administratively
am licensed or have been licensed to practice, provide to the Arkansas ADR Commission
of the Supreme Court of Arkansas, and/or the disciplinary agency of any other state in which I
Attorney Applicants:
I hereby authorize and request that the Board of Professional Conduct
Please check
any that apply, complete the relevant information,
and sign below.
PART
XII:
AUTHORIZATION AND
RELEASE
FORM
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ADDENDUM TO APPLICATION FOR CERTIFICATION OF MEDIATORS
Procedure for applicants for certification or renewal of certification who have been convicted of
or pled guilty to a violation of the law, disciplined by a professional organization, had
professional privileges curtailed, and/or have relinquished any professional privilege or license
while under investigation.
A. Applicants for certification with the Arkansas ADR Commission must
acknowledge the following information: (1) convictions of, guilty pleas to, or nolo
contendere pleas to violations of the law, including traffic violations resulting in
suspension or revocation of a driver’s license and DUI offenses; (2) discipline by
a professional organization; (3) curtailment of professional privileges; (4)
relinquishment of any professional privilege or license while under investigation.
An applicant against whom any of the above actions are pending shall likewise
acknowledge this fact.
B. Upon request of the Arkansas ADR Commission, the applicant must amend
his/her application to provide (1) information concerning the background of the
offense which led to conviction, plea, discipline, curtailment of professional
privileges and/or relinquishment of professional privilege or license; (2)
information concerning the length of time which has elapsed since the conviction,
plea, discipline, curtailment and/or relinquishment; (3) the age of the applicant at
the time of the conviction, plea, discipline, curtailment and/or relinquishment; (4)
evidence of rehabilitation since the conviction, plea, discipline, curtailment and/or
relinquishment.
C. The applicant may be asked to appear before the Arkansas ADR Commission to
discuss the information contained within the petition. The Commission will make
a determination as to whether the applicant should be certified or have
certification renewed.
D. If an applicant for certification or renewal of certification fails to acknowledge (1)
that he/she has been convicted of or pled guilty or nolo contendere to a violation
of the law, including traffic violations resulting in suspension or revocation of a
driver’s license and DUI offenses; (2) that he/she has been disciplined by a
professional organization; (3) that he/she has had his/her professional privileges
curtailed; (4) that he/she has relinquished any professional privilege or license
while under investigation; or (5) that any such actions are pending, the Arkansas
ADR Commission will immediately notify the applicant for certification or renewal
of certification that he/she will be denied certification or renewal of certification
or, if currently certified, removed from certification.
E. An adverse decision may be appealed to the full Commission within thirty days of
the date of such decision. The Commission may grant a hearing to the applicant.
ARKANSAS ALTERNATIVE DISPUTE RESOLUTION COMMISSION
Verification of Observation Form
S
ECTION I BACKGROUND INFORMATION
1. Name of Observer:
____________________________________________________________________
2. Name of Mediator:
____________________________________________________________________
S
ECTION II OBSERVATION INFORMATION
1. Date(s) of Observation: ______________________________________________
2. Nature of Case:
�Civil � Probate �Domestic Relations �Juvenile
3. Length of Mediation: ________________________________________________
4. Did the observer actively participate in the debriefing session following the
mediation? Yes � No � If no, please explain:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
5. Additional Comments:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
_______________________________ __________________
Signature of Mediator Date
Authorization For Release of Confidential Information
Contained Within the Arkansas Child Maltreatment Central Registry
I hereby request that the Arkansas Child Maltreatment Central Registry, PO Box 1437, Slot S 566, Little
Rock, Arkansas 72203, release any information their files may contain indicating the undersigned applicant
as an offender of true report of child maltreatment.
This information should be addressed to:
I understand that the name of any confidential informants, or other information which does not pertain to the
applicant as alleged perpetrator, will not be released.
Arkansas ADR Commission
Mediator Certification Program
625 Marshall Street
Little Rock, AR 72201
____________________________
Applicant’s Name (print or type)
____________________________
Maiden Name/Aliases
____________________________
Race Age DOB
Present Address:
____________________________
____________________________
From: _________ to ___________
Past Address:
____________________________
____________________________
From: _________ to ___________
____________________________
____________________________
From: _________ to ___________
____________________________
____________________________
From: _________ to ___________
________________________________
Social Security Number
Your Children
Please list FULL NAME and AGE of each child:
1) ________________________________
2) ________________________________
3) ________________________________
4) ________________________________
5) ________________________________
6) ________________________________
_________________________________________
Applicant’s Signature
County of ______________________, State of Arkansas
Acknowledges before me this _______ day of ________ 20___.
My Commission expires: _________________________________________________
Notary Public
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Completed 20 July 2020

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