I, (Name of ADR Practitioner) agree to conduct the
following ADR in the above-captioned case [check one]:
mediation in accordance with Rules 17-103 and 17-105
ADR other than mediation - specify type:
At the conclusion of the ADR, I agree to comply with the provisions of Rule 17-202 (h).
I solemnly affirm under the penalties of perjury that I have the qualifications prescribed by
the following Rules [check all that are true]:
Rule 17-205 (a) [Basic mediation]
Rule 17-205 (b) [Business and Technology]
Rule 17-205 (c) [Economic Issues - Divorce and Annulment]
Rule 17-205 (d) [Health Care Malpractice]
Rule 17-205 (e) [Foreclosure]
Rule 17-206 [ADR other than mediation]
None of the above.
Signature of ADR Practitioner