ORPHANS’ COURT FOR BALTIMORE COUNTY APPLICATION TO MEDIATE You

orphans’ court for baltimore county application to mediate you must be a trained mediator and conversant in estates and trusts to media

ORPHANS’ COURT FOR BALTIMORE COUNTY
APPLICATION TO MEDIATE
You must be a trained mediator and conversant in Estates and Trusts to
mediate cases in the Orphans’ Court for Baltimore County. Courses in
mediation and advanced mediation for Estates and Trusts are available
through MICPEL or other accredited programs.
Applicant Information:
Full
Name:______________________________________________________________
Home
Address:___________________________________________________________
_______________________________________________________________________
Work
Address:___________________________________________________________
_______________________________________________________________________
Home Telephone:( )_____________ Work Telephone:(
)______________________
Home Fax:( ) Work Fax:(___)________________________
E-mail:_________________________________________________________________
Please check how you prefer to be contacted:
____ Home Telephone _____ Work Telephone______Email
Formal Education:
Institution
City/State
Dates Attended
Degree
Major
__ Yes __ No
__ Yes __ No
__ Yes __ No
Work Experience:
Company
City/State
Dates Employed
Position
Specialties
Mediation Experience:
Briefly describe your mediation experience and the number of cases you
have handled in the last twelve months:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please list the year and name of any Continuing Mediation-Related
Seminars you have attended:
1.____________________________________
2.________________________________
3.____________________________________
4.________________________________
Please attach a copy of the certificates you have received from the
mediation seminars
y
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Mediation Application (Rev. 3/12/2007)
ou have attended.
Have you mediated cases involving Estates and/or Trusts? ____Yes____No
If yes, how many and what
types_____________________________________________
________________________________________________________________________
List all Courts in which you are presently admitted to mediate and
dates of admission:
Court County /State Date
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
If you are an Attorney
Are you an attorney in good standing? _______ Yes ________ No
Date admitted to Bar and for what state(s):
________________________________________________________________________
Briefly describe any experience in the practice of Estates and/or
Trusts:______________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Professional Affiliations/Community Activities:
Please list any professional affiliations and/or community activities
that you consider to be relevant (include Bar Associations and
Professional Societies).
Organization Position
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Facilities
==========
Do you have a location to conduct mediation in Baltimore City or
Baltimore County? ____Yes ____No
If yes, where is the facility located?
___________________________________________
Ethics, Monitoring and other Requirements:
_____ (Please initial) I agree to abide by any code of ethics approved
by the Maryland Court of Appeals, to submit to periodic monitoring of
court-connected mediation proceedings by a qualified person designated
by the Orphans’ Court for Baltimore County, and to comply with
reasonable procedures and requirements prescribed by the Orphans’
Court for Baltimore County, Maryland. (Required)
____ (Please initial) By completing this application, I agree to
accept a reasonable number of referrals on a reduced fee or pro bono
basis upon request by the Orphans’ Court for Baltimore County. Being
listed as a mediator does not guarantee that I will receive any case
referrals from the Orphans’ Court for Baltimore County nor does it
establish Court employee status for mediators.
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Mediation Application (Rev. 3/12/2007)
Criminal or Disciplinary Actions
Have you ever been convicted of any crime in Maryland or elsewhere
other than a minor traffic violation? If so, please provide details
including the conviction date, the location and name of the Court, the
offense and sentence imposed:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Are there currently any criminal charges pending against you in
Maryland or elsewhere other than minor traffic violations? If so,
please provide the date of the alleged incident, the location and the
name of the Court and the alleged offense:
________________________________________________________________________________________________________________________________________________________________________________________________________________________
Have you ever been disciplined by any Court, Administrative Agency,
Bar Association, or other Disciplinary Committee, Agency or Group in
Maryland or elsewhere for unethical conduct or for the violation of
any Code of Ethics? If so, please provide details including the date,
the disciplinary body, the conduct at issue and the disciplinary
action taken:
________________________________________________________________________________________________________________________________________________________________________________________________________________________
I do solemnly declare and affirm under the penalties of perjury that
the contents of the foregoing are true and correct.
________________________________________________________________________
SIGNATURE DATE
Please mail your completed application with supporting documentation
to:
Orphans’ Court for Baltimore County
Mediation Program
401 Bosley Avenue, Suite 501
Mail Stop 3508
Towson, Maryland 21204
If you have any questions or comments, please contact Juliet Fisher,
Esq., Mediation Coordinator, by phone (410)887-2096 or E-mail:
[email protected].
You will be notified by the Orphans’ Court for Baltimore County if
your application to serve as a mediator with the Baltimore County
Orphans’ Court is accepted.
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Mediation Application (Rev. 3/12/2007)