I am applying to be certified as a mediator under Local Rule 9.02. I qualify because I am: * A former state judge and bar member of that state. A retired federal judge. A member of any state or district court bar for 10 years and a current member of the court's bar. 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 Year192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024202520262027202820292030 On what date did you complete the Florida Supreme Court's Mediator Certification Program? * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024202520262027202820292030 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. What code is in the image? * Enter the characters shown in the image.
