MINNESOTA STATE COURT SYSTEM
	ADR-RULE 114 NEUTRAL ROSTER
	ORGANIZATION APPLICATION FORM
7/1/12
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

Organization Name:____________________________________________________

Director:  ____________________________________________________________

Address:  ____________________________________________________________

City/State/Zip:  ________________________________________________________

Daytime Phone:  (_____)__________________  Fax:  (_____)__________________

E-mail:  ______________________________________________________________

SECTION 2:  PLACEMENT REQUEST

	Indicate the neutral roster(s) for which you are requesting placement.  Also, indicate below the name of the individual from your organization who has applied or been approved for that roster.

	NOTE:  In order for your organization to be placed on a roster, at least one individual associated with your organization must be approved for that roster.  You are required to have individual neutral roster application forms on file in your organization for each of your neutrals.

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

		NAME:(please print)________________________________________________

Continued on next page

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

		NAME:(please print)________________________________________________

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

		NAME:(please print)________________________________________________

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

		NAME:(please print)________________________________________________

		Family Evaluative
		(Early Neutral Evaluation, Neutral Fact Finding)

		NAME:(please print)________________________________________________

SECTION 3:  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 4:  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 5:  COUNTY PREFERENCE

	Indicate those counties in which your organization is 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 6:  SIGNATURE

	I do hereby certify that the information provided in this application is true, that only neutrals who qualify under Supreme Court Rules on Alternative Dispute Resolution will participate in this program, and that, upon request, I will provide, documentation of training provided to neutrals.

	_________________________________________________	_______________
	Signature							Date