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)
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.
lease read and sign the following agreement:
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.
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
agree to adhere to the ethical standards for alternative dispute resolution providers as adopted by the
agree to accept at least one pro bono case (maximum 10 hours per case) or modest means case
am in good standing with the State Bar of California.
agree to indemnify, defend and hold harmless the Santa Clara County Superior Court, its judges, an
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.
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