Dispute Mediation Service, Inc.
PRACTICUM - Volunteer Mediator Information/Application
Mediator #_______________
Name: ________________________________________________Start Date:_______________
Address: _____________________________________________ Birth Date:_______________
________________________________________________________________ Sex: M___F___
City_______________ State_______________Zip_______________
Ethnicity:______________
Phone: (day)______________________________(night)_______________________________
Fax:____________________________________ Profession:____________________________
Employer:_____________________________________________________________________
Mediation Training:
Basic Training Received from:___________________________________________________
Date Completed:_______________________________________________________________
Family Mediation Training: Yes_____ No_____
Date & Trainer:________________________________________________________________
Total number of hours in Mediation Training:_________
Education Completed:
High School______________ College______________ Advanced Degrees_____________
Years education after H.S.______________
Special training or licenses:
______________________________________________________________________________
Foreign language fluency:__________________________________________(Sufficient to mediate in the language.)
Types of cases you would like to mediate: ______________________________________________________________________________ ______________________________________________________________________________
Types of cases you would like to mediate: (Areas in which you have special interest/expertise.) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Times available to mediate:
_________ Days ________ Evenings ________ Weekends _________ Anytime __________
Dispute Mediation Service, Inc.,
3400 Carlisle #240 LB-9, Dallas, TX 75204-1272
Phone (214) 754-0022 FAX (214) 754-0378
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