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SUPERIOR COURT OF CALIFORNIA COUNTY OF SANTA CLARA (The Superior Court of California, County of Santa Clara)

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SUPERIOR COURT OF CALIFORNIA
COUNTY OF SANTA CLARA
Elizabeth Strickland, ADR Administrator
191 North First Street
San Jose, California 95113
Fax: 408-882-2595
APPLICATION FOR FAMILY DIVISION
PRIVATE MEDIATION & COLLABORATIVE PRACTICE PANELS
(Do Not Alter this Form in Any Way).
Date:
Name:
Firm Name:
Address:
County:
Phone Number: Fax Number:
Email Address:
1. Check each panel for which you are applying: Mediation Collaborative Practice
2. D
escribe your education, including degrees and the dates received.
3. Briefly describe the ADR training you have received. For each training, give the trainer’s name, the
dat
es attended, and the total hours.
4. Describe the subject matter of five disputes for which you have been a mediator or collaborative
attorney in the past five years, with the dates. State whether you were a sole- or co-provider. (If
y
ou are applying for the mediation panel, describe 5 mediation cases handled. If you are applyi
ng
f
or the collaborative practice panel, describe 3 collaborative practice cases handled. If you ar
e
app
lying for both panels, describe 5 mediations and 3 collaborative cases, attaching extra pages if
necessary.)
•
•
•
•
•
5. List other court ADR panels of which you are a member, specifying the processes for which you
have qualified.
FM-1019 REV 01/23/15
APPLICATION FOR FAMILY DIVISION ADR PANEL Page 1 of 3
6. State the name of any organization for which you have provided ADR services during the past five
y
ears, giving the dates and the services you provided.
7. Check your areas of substantive expertise:
Adoption
Domestic Violence
Domestic Partnership
Estate Planning
Family Law (Divorce, Custody, etc.)
Insurance
Parentage
Real Estate
Tax
Other (specify):
8. W
hat is your State Bar No.?
a.
How many years have you been in active practice? If none, please explain.
b. What is or was the nature of your practice?
c. A
re you certified in any specialty? If so, please list.
9. D
escribe any legal writing or lecturing/teaching you have done.
10
. What is your ADR style?
11. List any languages, other than English, in which you can conduct ADR.
12
. Describe your fee schedule, including any sliding-scale or pro-bono provisions, as of the date of this
application.
13. Give any other information that should be considered in reviewing your application.
14. Please attach a recent resume or CV.
FM-1019 REV 01/23/15
APPLICATION FOR FAMILY DIVISION ADR PANEL Page 2 of 3
15. List the names and telephone numbers of three persons familiar with your mediation (for a mediator’s
application), litigation/evaluation and/or collaborative skills (for a collaborative practitioner’s application)
.
I
f you are applying for both panels, provide 3 mediation references and 3 collaborative practice
references, attaching extra pages if necessary. You may not duplicate references. You may attach a
letter of recommendation instead of a name.
N
ame Phone
Name Phone
Name Phone
P
lease read and sign the following agreement:
1. I
agree to be bound by the ADR rules of the Santa Clara County Superior Court.
2. I agree to waive any and all claims against the Santa Clara County Superior Court in connection with
my ADR services for a court-referred dispute.
3. I
agree to submit any fee dispute arising out of my ADR services for a court-referred dispute to
arbitration, either under Business and Professions Code section 6200 et seq. or by stipulation or court
order.
4. I
agree to adhere to the ethical standards for alternative dispute resolution providers as adopted by the
court.
5. I
agree to accept at least one pro bono case (maximum 10 hours per case) or modest means case
a
ye
ar.
6. I
am in good standing with the State Bar of California.
7. I
agree to indemnify, defend and hold harmless the Santa Clara County Superior Court, its judges, an
d
em
ployees from any claim, lawsuit, damages or liability of any kind, arising out of any conduct of mine in
the rendering of services to any person or persons in connection with my inclusion on the ADR providers’
list maintained by the Superior Court.
8. I do do not agree to have my background information posted on the Court’s ADR website.
Date: Name:
(please print)
Signature:
MAIL THIS APPLICATION AND ANY ATTACHMENTS TO:
ELIZABETH STRICKLAND, ADR ADMINISTRATOR
SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CLARA
191 N. FIRST STREET
SAN JOSE, CA 95113
OR FAX TO 408-882-2595
FM-1019 REV 01/23/15
APPLICATION FOR FAMILY DIVISION ADR PANEL Page 3 of 3
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Completed 29 June 2021

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