| NOTE: All fields on this form are REQUIRED. You will be contacted by a Dispute Resolution Section staff member regarding the mediation of foreclosure cases and any necessary training requirements. |
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| Last Name: |
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| First Name: |
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| Organization: |
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| Address: |
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| City: |
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| State: |
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| Zip Code: |
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| Telephone: |
(123) 456-7890 |
| E-mail: |
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| Are you an attorney? |
Yes
No |
If so, in what states are you licensed to practice?
(To make multiple selections, hold down the Ctrl key while making your selection.) |
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What counties are you willing to serve?
(To make multiple selections, hold down the Ctrl key while making your selection.) |
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| Years of mediation experience: |
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| Average number of cases per year: |
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| Do you have a background in foreclosure mediation? |
Yes
No |
| If so, please describe: |
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For which organizations do you mediate?
(To make multiple selections, hold down the Ctrl key while making your selection.) |
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| If other, please specify: |
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For which courts have you performed mediation?
(To make multiple selections, hold down the Ctrl key while making your selection.) |
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| If other, please specify: |
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For which courts have you done the most cases?
(To make multiple selections, hold down the Ctrl key while making your selection.) |
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| If other, please specify: |
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| What training have you had? |
| Basic Mediation |
Yes
No
If yes, how many hours, when, and where?
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| Uniform Mediation Act |
Yes
No If yes, how many hours, when, and where?
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| Foreclosure Mediation |
Yes
No If yes, how many hours, when, and where?
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Additional training
(Include no. of hours, when, where and any other applicable information.) |
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| Are you available to be a mentor? |
Yes
No If yes, for how many mentees?
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| Would you like to have a mentor to contact regarding foreclosure mediation? |
Yes
No |
| General Comments: |
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| I authorize the Dispute Resolution Section to share this information where appropriate: |
Yes
No |
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