Fillable Form 292: COUNTY REFERRAL LIST INFORMATION SHEET (Vermont Judiciary)

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Form 292: COUNTY REFERRAL LIST INFORMATION SHEET (Vermont Judiciary)

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COUNTY REFERRAL LIST INFORMATION SHEET
COUNTY:
Name:
Address:
Phone:
FAX:
E-Mail:
Alternative Dispute Resolution Service(s) Provided: (Check Applicable boxes)
Mediation
Arbitration
Early Neutral Evaluation
Other (please describe)
Education/Training/Certification:
Experience (please describe):
Hours Available:
Fees Charged:
I hereby agree to accept at least two referrals per year in actions in this county in which the clerk
has found that a party is entitled to proceed in forma pauperis pursuant to Rule 3.
I hereby agree to submit on an annual basis the information specified on this form.
Name (printed)
Date
In order to be placed on a county referral list, please return to the Superior Court Clerk in that County.
Signature
Form 292
9/03 SML
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Form 292: COUNTY REFERRAL LIST INFORMATION SHEET (Vermont Judiciary)

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Completed 23 November 2020

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