MINNESOTA STATE COURT SYSTEM
	ADR-RULE 114 NEUTRAL ROSTER
	INDIVIDUAL REAPPLICATION 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:_________________________________________________________________

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      N/A
If yes, indicate professional board:	

•	Is your professional license currently suspended?          No        Yes      N/A
	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 reapplying to:
You will only be reapproved to rosters that you were approved for previously.

		Civil Facilitative/Hybrid
		(Mediation, Mini-Trial, Med.-Arb., Other)

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

		Family Facilitative/Hybrid
		(Mediation, Mini-Trial, Med.-Arb., Other)

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

		Family Evaluative
		(Early Neutral Evaluation, Neutral Fact Finding)

SECTION 4:  CONTINUING EDUCATION TRAINING

To be placed back on the roster, you must complete the continuing education requirement for the current reporting period.

Neutrals reapplying to a facilitative/hybrid panel are required to take 18.00 hours per three-year reporting period.  Neutrals reapplying to any of the other panels are required to take 9.00 hours per three-year reporting period.  Neutrals who are reapplying to more than one panel are required to take no more than 18.00 hours per three-year reporting period.  Continuing education courses must be ADR related but do not have to be certified.

	Indicate the continuing education course(s) you attended for the current reporting period.  Period covering the year, _________ to present.

Title:  							How did this course enhance your skills and abilities
Sponsor:  					in ADR processes?
Location:  
Date(s):  
Hours of actual education:  

Title:  							 How did this course enhance your skills and abilities
Sponsor:  					 in ADR processes?
Location:  
Date(s):  
Hours of actual education:  

Title:  							How did this course enhance your skills and abilities
Sponsor:  					in ADR processes?
Location:  
Date(s):  
Hours of actual education:  

Title:  							 How did this course enhance your skills and abilities
Sponsor:  				 in ADR processes?
Location:  
Date(s):  
Hours of actual education:  

Title:  							 How did this course enhance your skills and abilities
Sponsor:  				 in ADR processes?
Location:  
Date(s):  
Hours of actual education:  

Title:  							 How did this course enhance your skills and abilities
Sponsor:  				 in ADR processes?
Location:  
Date(s):  
Hours of actual education:  

Title:  							 How did this course enhance your skills and abilities
Sponsor:  				 in ADR processes?
Location:  
Date(s):  
Hours of actual education:  

SECTION 5:  SIGNATURE

	I do hereby certify that the information provided in this application is true.

	____________________________________________________________________
	Signature						      Date