Circuit Court of Henry County

Mediator Application Form

Name                                                                                                                                            
Office Address                                                                                                                                            
                                              E-mail                                                                                  
Telephone                                            Fax                                                                                      
Person to contact for referral                                                                                                                                            
Telephone                                               Fax                                                                                      
Date admitted to practice                                                                                             
Law firm affiliation or employer                                                                                             
Subject areas of legal practice                                                                                             
Mediation training and experience:
When and from whom did you receive mediation training?
                                                                                                                                                                                           
What is the total number of cases you have mediated?                                              
Describe the type of cases which you will mediate?
                                                                                                                                                                                           
Will you provide references for those upon request?                                              
If you have references which you would like to provide here, please give names, addresses and telephone numbers of
counsel, representatives or parties familiar with your mediation work.
                                                                                                                                                                                          
What rate of compensation will you charge for mediation?  Please indicate if travel time is compensable and any other charges.
                                                                                                                                                                                           
Do you normally require written submissions from the parties about their respective positions to be given to you in advance
of the mediation?                                                                                                                                                                 
All of the above statements are complete and accurate to the best of my knowledge.
                                                                            
Mediator Date

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