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