Fillable Form 1.: ARKANSAS ALTERNATIVE DISPUTE RESOLUTION COMMMISSION educational (Administrative Office of the Courts)

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Form 1.: ARKANSAS ALTERNATIVE DISPUTE RESOLUTION COMMMISSION educational (Administrative Office of the Courts)

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U.S.A. forms for Administrative Office of the Courts

BROWSE ADMINISTRATIVE OFFICE OF THE COURTS (AR) FORMS

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ARKANSAS ALTERNATIVE DISPUTE RESOLUTION COMMMISSION
625 Marshall Street, Suite 1200
Little Rock, AR 72201
Phone:
(501) 682-9400
Fax:
(501) 682-9410
APPLICATION
FOR ACCREDITATION OF CONTINUING MEDIATION EDUCATION
ACTIVITY
1.
Sponsoring Organization: ____________ ___________ Sponsor #: ________________________
Address: __________________________________ Phone #:
_
_______________
FAX #: _______________________ E-mail: __
_
2. Title of
educational
activity:
3.
Date(s)
& location(s):
_
4.
Registration Fee:
$
___________
5. Writing
surface
available: ___
yes ___no
6.
Delivery Method(s): __
_ faculty
in room with
participants
___
phone
to
broadcast
site
___ satellite ___ videotape
presentation (requires
moderator) ___
"live"
interactive computer
webcast
7. Advertised to
: _
Mediators __
Clients
__ Others
(specify
).
_
8. List any
admission
restrictions:
_
9. Is this
an
'in-house" activity?
(Access
limited to
members
of one private organization):
_
___yes ____no
10.
Method
of
evaluation: __
participant
critique __
independent
evaluator __
none
11.
Description
of
materials
to be distributed: total
pages __
before
program __
after program
_ other
12.
REQUIRED ATTACHMENTS
to this
application:
a.
Time schedule
(brochure,
outline,
description)
b.
Table
of
contents
or equivalent
13.
Total minutes
of
instruction,
excluding
breaks
,
meals
or introductions:
c.
Faculty name(s) & credentials
(if not in brochure)
General:
14.
Approval
by other states:
granted
by
denied
by
_
15. Submitted by
: ___
employee
of sponsor/provider _
individual
mediator
SPONSOR
OBLIGATIONS: Sponsor acknowledges
and
agrees
to
comply
with
Arkansas ADR
Commission CME
rules.
Sponsor
Representative:
_
Mediator
Name:
_
Certification #:
_
Address: _
_
Signature:
Title: ________________________________________ Phone:
Date:
_
CME1
Signature:
_
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Form 1.: ARKANSAS ALTERNATIVE DISPUTE RESOLUTION COMMMISSION educational (Administrative Office of the Courts)

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Completed 20 July 2020

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