To qualify for certification as a mediator under Local Rule 4.02, a lawyer must establish: membership for at least the last ten years in the bar of any state or the District of Columbia, membership in good standing in The Florida Bar and the Middle District bar, and completion of the Florida Supreme Court’s certified mediator training and certification by the Florida Supreme Court of good standing as a circuit court mediator. The following information supports my application. First Name * Middle Name Last Name * Suffix Jr., Sr., etc. Check the areas of practice or experience that best describe your legal background. * Administrative Law Admiralty Business Litigation Civil Rights Construction Contracts Environmental Law Insurance Intellectual Property Labor Personal Injury Personal Property Products Liability Professional Liability Real Property Social Security Tax List the names and dates of membership in any state bar or the District of Columbia bar. Are you a member in good standing of these bars? Yes No What is your Florida Bar number? On what date were you admitted to this court's bar? Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025202620272028202920302031 On what date did you complete the Florida Supreme Court's Mediator Certification Program? * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025202620272028202920302031 Enter the number of mediation conferences at which you have represented a litigant. * In which divisions are you willing to serve as a mediator? * Fort Myers Jacksonville Ocala Orlando Tampa Firm Information Firm Name Address Line 1 * Address Line 2 City * State * - Select - AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code + 4 * Office Phone Number * NNN-NNN-NNNN Cell Phone Number NNN-NNN-NNNN Office Fax Number NNN-NNN-NNNN Email Address * Signature Signature * Type your full name, prefixed with "s/", in the field above to acknowledge that you have read and understand the information in this document. CAPTCHAThis question is to prevent automated spam submissions.
