APPENDIX I (L.R. 4.24, fka 4.11)
MEDIATOR QUALIFICATION QUESTIONNAIRE
Name__________________________________________________________________ Business Address_________________________________________________________ Telephone_______________________________________________________________
List any formal post-law school training for mediation (including seminars). Include the dates of the formal training:
List the number of cases you acted as mediator:
Check off the following areas you feel confident in mediating: Tort Commercial Products Liability Administrative Appeals Workers Compensation ___________________ ___________________ ___________________ ___________________ ___________________
List any professional associations affiliated with mediation:
By submitting this application, I acknowledge I am familiar with Local Rule 4.25 on mediation, and I agree to comply with those rules.
___________________________________ Signature
*This application must be submitted to: Manager, Court Administration Government Services Center 315 High Street, 3rd Floor Hamilton, Ohio 45011