MINNESOTA STATE COURT SYSTEM
	ADR-RULE 114 NEUTRAL ROSTER
	ORGANIZATION REAPPLICATION 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:  ________________________________________________________________

Director:  ____________________________________________________________________

Address:  ____________________________________________________________________

City/State/Zip:  _______________________________________________________________

Daytime Phone:  (________)_________________   Fax:  (________)______________

E-mail:  ________________________________________________________________________

SECTION 2:  PLACEMENT REQUEST

	Please indicate the neutral roster(s) for which your organization is reapplying to.  Also indicate 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 back 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) 

		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:  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