Minnesota state court system



Download 90.27 Kb.
Date02.06.2016
Size90.27 Kb.

MINNESOTA STATE COURT SYSTEM


ADR-RULE 114 NEUTRAL ROSTER

INDIVIDUAL APPLICATION FORM

3/8/13

INSTRUCTIONS:
Complete form and mail along with the $60.00 non-refundable processing fee to:
Alternative Dispute Resolution Program

120 Minnesota Judicial Center

25 Rev. Dr. Martin Luther King Jr. Blvd.

St. Paul, MN 55155-1500

adr@courts.state.mn.us
Make check payable to: State of Minnesota
Processing time is usually 2-3 weeks and a confirmation letter will be sent after approval.



SECTION 1: GENERAL INFORMATION
Name:________________________________________________________________
Occupation*: __________________________________________________________
Address: ______________________________________________________________
City/State/Zip: _________________________________________________________

Daytime Phone: (________)______________ Fax: (________)__________________

E-mail:_________________________________________________________________


*If you are a retired judge/referee your experience on the bench qualifies you to be placed on the Civil Adjudicative/Evaluative and Family Adjudicative rosters (a domestic abuse course is still required for the family adjudicative panel). Indicate your judicial experience under occupation.
SECTION 2: LICENSE INFORMATION
Are you licensed as an attorney by the State of Minnesota No Yes

If yes, indicate Attorney ID # and CLE Reporting Period 1 2 3

Are you licensed by any other professional boards? No Yes NA

If yes, indicate professional board:
Is your professional license currently suspended? No Yes NA

If yes, please provide effective dates for the suspension:
I certify I have not had a professional license revoked, I have not been refused membership or practice rights in a profession, nor have I been involuntarily banned, dropped or expelled from any profession.
_____________________________________________ _______________

Signature Date

SECTION 3: PLACEMENT REQUEST
Please indicate the neutral roster(s) for which you are requesting placement:
Civil Facilitative/Hybrid

(Mediation, Mini-Trial, Med.-Arb., Other)

YOU MUST COMPLETE SECTIONS 4, 5, 11 and 12

Civil Adjudicative/Evaluative

(Arbitration, Consensual Special Magistrate, Moderated Settlement Conference, Summary Jury Trial, Early Neutral Evaluation, Neutral Fact Finding)

YOU MUST COMPLETE SECTIONS 4, 6, 11 and 12


Family Facilitative/Hybrid

(Mediation, Mini-Trial, Med.-Arb., Other)

YOU MUST COMPLETE SECTIONS 7, 8, 11 and 12


Family Adjudicative

(Arbitration, Consensual Special Magistrate, Moderated Settlement Conference, Summary Jury Trial)

YOU MUST COMPLETE SECTIONS 7, 9, 11 and 12


Family Evaluative

(Early Neutral Evaluation, Neutral Fact Finding)

YOU MUST COMPLETE SECTIONS 7, 10, 11 and 12




SECTION 4: CIVIL LAW AREAS OF EXPERIENCE
Indicate your areas of civil law experience for listing on the Minnesota Supreme Court website’s searchable roster (you must choose at least one).
Bankruptcy/Creditor-Debtor Insurance

  • Business/Commercial Personal Injury

  • Complex Litigation/Class Actions Professional Liability/ Malpractice

  • Construction Real Estate

Employment Securities

General Civil



SECTION 5: CIVIL FACILITATIVE/HYBRID
Indicate the 30 hour certified civil course you attended.

Course Dates:

(xx/xx/xx – xx/xx/xx)*




Course Title:

Course Sponsor:

Course Hours:

*Course dates must include month, day, and year in order for application to be processed.
SECTION 6: CIVIL ADJUDICATIVE/EVALUATIVE
Indicate the 6 hour certified civil course you attended.

Course Dates:

(xx/xx/xx – xx/xx/xx)*




Course Title:

Course Sponsor:

Course Hours:

*Course dates must include month, day, and year in order for application to be processed.
SECTION 7: FAMILY LAW AREAS OF EXPERIENCE
Indicate your areas of family law experience for listing on the Minnesota Supreme Court website’s searchable roster (you must choose at least one).
Adoption Parenting Time/Child Visitation

Child Custody Paternity

Child Support Post-Dissolution Matters

Dissolution/Divorce Spousal Maintenance

General Family Law Valuation of Property

Minn. Stat. § 518.1751, subd. 2(c) states that individuals who have completed the 40 hour family mediation training are eligible to serve as parenting time expeditors, subject to continuing education requirements. If you have completed the family training and would like to be listed on the Minnesota Supreme Court website as available for parenting time expediting, please check the following box. You should also contact the local court administrators if you would like to be on the county rosters pursuant to Minn. Stat. § 518.1751, subd. 2(b).


Parenting Time Expeditor

SECTION 8: FAMILY FACILITATIVE/HYBRID
Complete only the boxes applicable to the family ADR training you have completed.


  • Indicate the 40 hour certified family mediation course you attended.*

*This course must have been taken after January 1, 1997. If taken prior to 1997, a petition for course certification must be submitted prior to application. The petition may be found at http://www.mncourts.gov/documents/0/public/Alternative_Dispute_Resolution/NEW_individual_family_training_course_petition.doc or contact the ADR program at ADR@courts.state.mn.us

Course Dates:

(xx/xx/xx – xx/xx/xx)*




Course Title:

Course Sponsor:

Course Hours:

*Course dates must include month, day, and year in order for application to be processed.
Indicate the 30 hour certified civil mediation course and the certified family mediation "bridge" course you attended.

Course Dates:

(xx/xx/xx – xx/xx/xx)*




Course Title:

Course Sponsor:

Course Hours:

Course Dates:

(xx/xx/xx – xx/xx/xx)*




Course Title:

Course Sponsor:

Course Hours:

*Course dates must include month, day, and year in order for application to be processed.
If the above course(s) did not include 6 hours of certified domestic abuse issues training, indicate the certified domestic abuse course you attended. This course has not been offered before 1997.


Course Dates:

(xx/xx/xx – xx/xx/xx)*




Course Title:

Course Sponsor:

Course Hours:



SECTION 9: FAMILY ADJUDICATIVE
To qualify you must have at least five years of professional experience in the area of family law and be recognized as a qualified practitioner in your field.
I certify that I have five years of professional experience in the family law area.
_________________________________________________ ________________

Signature Date
Indicate which document (copy) you have attached as proof of recognition:
Professional License

Professional Certificate

Faculty membership of approved continuing education courses for family law

Service as court-appointed adjudicative neutral

Service as referee or guardian ad litem

Acceptance by peers as expert in this field

Other:___________________________________________________________
Indicate the 6 hour certified family adjudicative course you attended.

Course Dates:

(xx/xx/xx – xx/xx/xx)*




Course Title:

Course Sponsor:

Course Hours:

*Course dates must include month, day, and year in order for application to be processed.
Indicate the 6 hour certified domestic abuse course you attended. This course was not offered before 1997.

Course Dates:

(xx/xx/xx – xx/xx/xx)*




Course Title:

Course Sponsor:

Course Hours:

*Course dates must include month, day, and year in order for application to be processed.
SECTION 10: FAMILY EVALUATIVE
I certify that I have at least five years of experience as a family law attorney, as an accountant dealing with divorce-related matters, as a custody and visitation psychologist, or as another professional working in the area of family law who is recognized as a qualified practitioner.
_________________________________________________ ________________

Signature Date

Indicate the 2 hour certified course you attended.



Course Dates:

(xx/xx/xx – xx/xx/xx)*




Course Title:

Course Sponsor:

Course Hours:

*Course dates must include month, day, and year in order for application to be processed.

Indicate the 6 hour certified domestic abuse course you attended. This course has not been offered before 1997.



Course Dates:

(xx/xx/xx – xx/xx/xx)*




Course Title:

Course Sponsor:

Course Hours:

*Course dates must include month, day, and year in order for application to be processed.
SECTION 11: COUNTY PREFERENCE
Indicate those counties in which you are willing to provide ADR services:
All 87 counties
All 7 metro counties (Anoka, Carver, Dakota, Hennepin, Ramsey, Scott, Washington)
The following individual counties: please circle

Aitkin

Anoka


Becker

Beltrami


Benton

Big Stone

Blue Earth

Brown


Carlton

Carver


Cass

Chippewa


Chisago

Clay


Clearwater

Cook


Cottonwood

Crow Wing

Dakota

Dodge


Douglas

Faribault

Fillmore

Freeborn


Goodhue

Grant


Hennepin

Houston


Hubbard

Isanti


Itasca

Jackson


Kanabec

Kandiyohi

Kittson

Koochiching



Lac Qui Parle

Lake


Lake of the Woods

Le Sueur


Lincoln

Lyon


Mahnomen

Marshall


Martin

McLeod


Meeker

Mille Lacs

Morrison

Mower


Murray

Nicollet


Nobles

Norman


Olmsted

Otter Tail

Pennington

Pine


Pipestone

Polk


Pope

Ramsey


Red Lake

Redwood


Renville

Rice


Rock

Roseau


Scott

Sherburne

Sibley

St. Louis



Stearns

Steele


Stevens

Swift


Todd

Traverse


Wabasha

Wadena


Waseca

Washington

Watonwan

Wilkin


Winona

Wright


Yellow Medicine



SECTION 12: SIGNATURE
I do hereby certify that the information provided in this application is true.
_________________________________________________ ________________

Signature Date

ADR Roster – Individual Application Page of



Share with your friends:




The database is protected by copyright ©essaydocs.org 2020
send message

    Main page