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SUPREME COURT OF NEVADA OFFICE OF THE CLERK (Supreme Court of Nevada)

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SUPREME COURT OF NEVADA
OFFICE OF THE CLERK
201 SOUTH CARSON STREET, CARSON CITY NV 89701-4702
TELEPHONE (775) 684-1600
APPLICATION FOR SUPREME COURT SETTLEMENT JUDGE
PERSONAL INFORMATION CONTACT INFORMATION
Name (First, Middle, Last) Business Telephone
Business Address Home Telephone
City State Zip Telefax
Home Address Cellular Telephone
City State Zip E-Mail Address
OTHER
Geographic Service Areas
Reno/Carson/Tahoe ______ Central Nevada _____
Northeastern Nevada _____ Greater LV Area _____
List Foreign Languages, or Sign Language, in Which
You Have Sufficient Fluency to Serve as a Mediator
ADMISSION TO PRACTICE LAW
Nevada Bar
Date of Admission ________________
Active _____
Inactive_____
Other (specify)
Other Bar
Date of Admission ________________
Active _____
Inactive_____
Other (specify)
Other Bar
Date of Admission ________________
Active _____
Inactive_____
Other (specify)
INSTRUCTIONS FOR SETTLEMENT JUDGE APPLICATION
1. This application is to be submitted to the Clerk of the Supreme Court of the State of Nevada. The application
must be mailed or delivered to the Clerk’s Office at 201 South Carson Street, Carson City, NV 89701-4702.
2. Application for appointment to the panel of settlement judges must be made using this form. You may use
additional sheets if needed.
3. Please type or print all information requested. Your original signature on the application is required.
No facsimile copies of this application will be accepted.
4. The Supreme Court of Nevada may refer your application to the State Bar of Nevada for review and
investigation.
5. Upon referral, the State Bar shall investigate the applicant’s qualifications and fitness to serve as a
settlement judge, including, but not limited to, verification of the applicant’s educational background,
employment history, professional licensure and any related disciplinary proceedings, and criminal
history.
6. No later than 90 days from the date of referral, the State Bar shall transmit to the Supreme Court a
certificate concerning the applicant’s qualifications and fitness.
7. Please direct any questions regarding the application to the Supreme Court Clerk’s Office.
8. The information contained herein will be kept confidential.
SUPREME COURT OF NEVADA APPLICATION FOR SETTLEMENT JUDGE Page 1 of 7 Adopted by Order 3/10/06
OTHER PROFESSIONAL OR OCCUPATIONAL LICENSES
Name of Entity Issuing License Date License Issued Status of License
AFFILIATION WITH MEDIATION ORGANIZATION OR SERVICE
Name of Service Address of Service
Telephone Number City State Zip
Length of Membership Position Held
AFFILIATION WITH OTHER CONFLICT RESOLUTION OR ADR SERVICE
Name of Service Address of Service
Telephone Number City State Zip
Length of Membership Position Held
MEDIATION QUESTIONS
Are you a full-time mediator?
Yes______
No______
When did you first begin serving as a mediator?
Approximately how many cases have you mediated?
How many appellate mediations have you participated in?
As a mediator ____________________As an advocate ______________________As a party _______________________
EDUCATION AND TRAINING
College, University or Professional School
(List all undergraduate and graduate work)
Dates
Attended
Number of
Credits
Degree Received
Name of Institution Location
From To Qtr. Sem. (AA, BS, etc.)
Major
Business, Correspondence, Trade,
Technical or Vocational School
Dates
Attended
Full
Time
Part
Time
Date
Certif.
Received
Name of Institution Location
From To Y/N Hrs/
Wk
Title of Program or
Subjects Taken
SUPREME COURT OF NEVADA APPLICATION FOR SETTLEMENT JUDGE Page 2 of 7 Adopted by Order 3/10/06
MEDIATION TRAINING
Training Classes Attended/Course Title and
Location
Dates of Attendance Number
of Hours
From To
Completion Validation/
Certificate:
Yes ____ No ____
Provider Name and Address
Training Classes Attended/Course Title and
Location
Dates of Attendance Number
of Hours
From To
Completion Validation/
Certificate:
Yes ____ No ____
Provider Name and Address
Training Classes Attended/Course Title and
Location
Dates of Attendance Number
of Hours
From To
Completion Validation/
Certificate:
Yes ____ No ____
Provider Name and Address
OTHER CONFLICT RESOLUTION OR ALTERNATE DISPUTE RESOLUTION TRAINING
Training Classes Attended/Course Title and
Location
Dates of Attendance Number
of Hours
From To
Completion Validation/
Certificate:
Yes ____ No ____
Provider Name and Address
Training Classes Attended/Course Title and
Location
Dates of Attendance Number
of Hours
From To
Completion Validation/
Certificate:
Yes ____ No ____
Provider Name and Address
Training Classes Attended/Course Title and
Location
Dates of Attendance Number
of Hours
From To
Completion Validation/
Certificate:
Yes ____ No ____
Provider Name and Address
SUPREME COURT OF NEVADA APPLICATION FOR SETTLEMENT JUDGE Page 3 of 7 Adopted by Order 3/10/06
EMPLOYMENT HISTORY
Name of Employer Telephone Number
Address
Major Areas of Specialization or Subject Matter Expertise
Any Other Significant Experience That You Think Qualifies You to Serve as a Settlement Judge
Dates of Employment Reason for Leaving
Name of Employer Telephone Number
Address
Major Areas of Specialization or Subject Matter Expertise
Any Other Significant Experience That You Think Qualifies You to Serve as a Settlement Judge
Dates of Employment Reason for Leaving
Name of Employer Telephone Number
Address
Major Areas of Specialization or Subject Matter Expertise
Any Other Significant Experience That You Think Qualifies You to Serve as a Settlement Judge
Dates of Employment Reason for Leaving
SUPREME COURT OF NEVADA APPLICATION FOR SETTLEMENT JUDGE Page 4 of 7 Adopted by Order 3/10/06
BACKGROUND INFORMATION
1. Are you now or have you ever been named as a defendant in any lawsuit or
arbitration proceeding involving allegations of fraud, misappropriation of funds,
misrepresentation or breach of fiduciary duty?
Yes No
If you answer "Yes" you must attach to this application:
(a) A written statement summarizing the details of each incident,
(b) A copy of the Petition, Complaint or other document that commenced the
lawsuit or arbitration, and
(c) A copy of the official document, which demonstrates the resolution of the
charges or any final judgment.
2. Have you or any business in which you are or were an owner, partner, officer or
director ever been involved in an administrative proceeding regarding any
professional or occupational license?
Yes No
"Involved" means having a license censured, suspended, revoked,
canceled, terminated; or, being assessed a fine, placed on probation or
surrendering a license to resolve an administrative action.
"Involved" also means having a license application denied or the act of
withdrawing an application to avoid a denial. You may exclude
terminations due solely to noncompliance with continuing education
requirements or failure to pay a renewal fee.
If you answer "Yes" you must attach to this application:
(a) A written statement identifying the type of license and explaining the
circumstances of each incident,
(b) A copy of the Notice of Hearing or other document that states the charges and
allegations, and
(c) A copy of the official document, which demonstrates the resolution of the
charges or any final judgment.
3. Have you ever been convicted of, or are you currently charged with committing a
crime?
Yes No
"Crime" includes a misdemeanor, felony or a military offense. You may
exclude misdemeanor traffic citations and juvenile offenses.
"Convicted" includes, but is not limited to, having been found guilty by
verdict of a judge or jury, having entered a plea of guilty, by Alford plea,
nolo contendere, or having been given probation, a suspended sentence or
a fine.
If you answer "Yes" you must attach to this application:
(a) A written statement explaining the circumstances of each incident,
(b) A copy of the charging document, and
(c) A copy of the official document that demonstrates the resolution of the charges
or any final judgment.
SUPREME COURT OF NEVADA APPLICATION FOR SETTLEMENT JUDGE Page 5 of 7 Adopted by Order 3/10/06
BACKGROUND INFORMATION (continued)
4. Have you ever received a public or private reprimand or letter of caution, or been
denied admission, suspended or disbarred from the practice of law in Nevada or
any other state?
Yes No
If you answer "Yes" you must attach to this application:
(a) A written statement explaining the circumstances of each incident,
(b) A copy of the charging document, and
(c) A copy of the filed order that demonstrates the resolution of the charges.
PROFESSIONAL REFERENCES
(Minimum of 2 references required. Do not include Supreme Court Justices or Supreme Court personnel as your references)
Last Name First Name M.I. Telephone Number
Address
Profession
Last Name First Name M.I. Telephone Number
Address
Profession
Last Name First Name M.I. Telephone Number
Address
Profession
Last Name First Name M.I. Telephone Number
Address
Profession
SUPREME COURT OF NEVADA APPLICATION FOR SETTLEMENT JUDGE Page 6 of 7 Adopted by Order 3/10/06
CERTIFICATION
(Please read and sign the following certification. You have a duty to notify the Supreme Court
within 30 days of any significant change in the information contained within this application.)
I hereby certify under penalty of perjury that all of the information submitted in this application
and any attachments is true and complete. I am aware that submitting false information or omitting
pertinent or material information in connection with this application is grounds for removal from the
approved Settlement Judge List or denial of my appointment as a settlement judge and may subject me
to civil or criminal penalties. Further, I grant permission to the Supreme Court of Nevada, acting
through the State Bar of Nevada, to verify the information contained in this application with any federal,
state or local government agency; any current or former employer; any public or private mediation
organization or service; and the references listed above.
Original Signature of Applicant Applicant's Name (Printed or Typed) Date
SUPREME COURT OF NEVADA APPLICATION FOR SETTLEMENT JUDGE Page 7 of 7 Adopted by Order 3/10/06
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Completed 15 August 2020

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