APPLICANT INFORMATION
Montgomery County Circuit Court
Mediator Application
Pursuant to Title 17 of the Maryland Rules
Please e-mail this application to MediatorApp@mcccourt.com with supporting documentation.
NAME:
Last
First Middle
HOME ADDRESS:
Number and Street
City State
Zip Code
TELEPHONE NUMBERS:
(Enter Numbers only)
(Enter Numbers only)
I am interested in mediating cases from the following circuit courts:
Page 1 of 6
BUSINESS ADDRESS:
Number and Street
City State
Zip Code
FAX NUMBERS:
Allegany
Dorchester
Prince George's
Washington
Wicomico
Worcester
Talbot
Somerset
Saint Mary's
Queen Anne's
Frederick
Garrett
Harford
Montgomery
Kent
Howard
Charles
Carroll
Caroline
Cecil
Calvert
Baltimore Couty
Baltimore City
Anne Arundel
E-MAIL ADDRESS:
Home
Work
Mobile
Home
Work
Page 2 of 6
Please describe the types of cases and number of cases you have mediated within the past twelve months.
Case Type (e.g., divorce, personal injury) Number of Cases
% Court-Referred
% Resolved
Please identify your areas of expertise. (Check all that apply.)
Breach of Contract
Medical Malpractice
Personal Injury
Products Liability
Real Estate
Other:
Workers Compensation
Trusts and Estates
Legal Malpractice
Divorce/Marital Property
Intellectual Property
Labor and Employment
Custody/Visitation
Construction
Community/Neighborhood Association
Business/Corporate
QUALIFICATIONS
I am at least 21 years old.
I am familiar with the Maryland rules, statutes, and practices governing mediation in
the circuit courts.
I have mediated or co-mediated at least two civil cases.
I have completed at least 40 hours of basic mediation training.
For mediators seeking referrals of business and technology cases, I have also, within the two years
preceding my application, served as a mediator in at least five (5) non-domestic civil mediations, at least
two of which involved types of conflicts assigned to the business and technology track.
For mediators seeking referrals of divorce cases, I have also completed at least 20 hours of skill-based
training in economic issues in divorce and annulment cases and I have served as a mediator or co-mediator
in at least two cases involving marital property/economic issues.
For mediators seeking referrals of medical malpractice cases, I have also within the two years preceding
my application, served as a mediator in at least five (5) non-domestic civil mediations, at least two of which
involved types of conflicts involving medical malpractice and I am knowledgeable about medical
malpractice claims through experience, training or education.
Dates Attended
Page 3 of 6
EDUCATION
Please list colleges, universities and other higher education institutions attended.
Institution Major City
State
(Country)
From To
Degree Attained
MEDIATION TRAINING
Total Hours Location DateTrainer/Organization
Page 4 of 6
ETHICS, MONITORING PROCEDURES AND OTHER REQUIREMENTS
I agree to abide by a Code of Ethics approved by the Court of Appeals, to submit to periodic monitoring
of court-ordered mediation sessions by a qualified mediator designated by the county
administrative judge, and to comply with reasonable procedures and requirements prescribed in
the court’s case management plan relating to diligence and quality assurance.
I am willing to accept a reasonable number of referrals on a reduced fee or pro bono basis upon request
by the court.
I agree to be responsible for finding an appropriate (if necessary, ADA accessible) location for mediation
sessions that is convenient for the parties.
Please list any professional affiliations and/or community activities that you consider relevant to your designation
as a mediator.
PROFESSIONAL AFFILIATIONS/COMMUNITY ACTIVITIES
LANGUAGE FLUENCY
OTHER OCCUPATIONS
Please list any other occupations that you have or have had (within the last ten (10) years) that may assist in your
performance of duties as a mediator.
Page 5 of 6
CRIMINAL OR DISCIPLINARY ACTIONS - PENDING COMPLAINTS
A)
B)
If yes, please provide details including the date, the disciplinary body, the conduct at issue and
the disciplinary action taken.
If yes, please provide details including relevant dates, the conduct at issue and the
disciplinary body involved.
Have you ever been disciplined by any court, administrative agency, bar association, or other
disciplinary committee, agency or group in Maryland or elsewhere for unethical conduct or
for the violation of any code of ethics?
C)
D)
Have you ever been convicted of any crime in Maryland or elsewhere other than a minor traffic
violation?
Yes
No
If yes, please provide details including the conviction date, the location and name of the court,
the offense, and the sentence imposed.
Are there currently any criminal charges pending against you in Maryland or elsewhere other than
minor traffic violations?
If, yes please provide details including the date of the alleged incident, the location and
name of the court and the alleged offense.
Yes No
Yes No
Are there any complaints or charges currently pending against you by any court, administrative
agency, Bar Association, or other disciplinary committee, agency or group in Maryland or elsewhere
for unethical conduct or for the violation of any Code of Ethics?
Yes
No
Being listed for designation as a mediator does not guarantee that you will receive any case referrals from the
circuit court, nor does it establish court employee status for mediators. Please read Maryland Rules 17-101
through 17-108 containing circuit court rules applicable to alternative dispute resolution and to being listed for
designation as a mediator.
Name
Business telephone
Business address
Home address
E-mail address
Page 6 of 6
DOCUMENTATION - CHECKLIST
INCLUSION OF INFORMATION ON THE COURT'S WEBSITE
I have attached the following:
I consent to the court posting the following information on the court's website :
A copy of my driver’s license, state identification card, passport or other official signed photo
identification as proof that I am at least 21 years old.
A copy of a certificate or other proof documenting my completion of at least 40 hours of mediation
training that meets the requirements of Maryland Rule 17-104.
Copies of any additional certificates documenting my completion of the additional training required to
mediate divorce cases, business and technology cases, or medical malpractice cases, if applicable.
Please see Maryland Rule 17-205.
I DO NOT consent to the court posting my information on the court's website.
A copy of my resume, references, or other information to support my application.
Signature of Applicant:
Signature Date:
I hereby represent that all information provided by me in this application is true and correct:
MediatorApp@mcccourt.com
WHEN EMAILING THIS APPLICATION, PLEASE ACKNOWLEDGE THE ABOVE NOTICE BY
TYPING YOUR INITIALS IN THE BOX TO THE RIGHT:
Save As
Print Form