Mediator Certification Application

Information on the Mediate.com Certification Program is here.

Certification Application:

Name	first last
Email
Mediate.com Member #:
Confirm you have listed at least 100 hours of training in your directory record:	yes  no   (Required)
Confirm you have provided complete information in your directory record:	college & graduate degrees  professional background  credentials and affiliations  trainings listed  mediation practice & approach  mediation fees  recent picture   (R)
Confirm that your self-evaluation level is shown:	Senior  Practitioner  Associate  None of the above   (R)
Confirm you have designated your mediation cases by practice areas on my Mediate.com Directory Listing:	yes  no   (R)
Confirm you have indicated whether you have liability insurance in your directory record:	yes  no   (R)
Confirm you have displayed your references or have available on request:	yes  no   (R)
Confirm you agree to the stated Mediator Standards of Practice:	yes  no   (R)
Confirm you will verify 12 hours of annual continuing education:	yes  no   (R)
Have you ever been convicted of a felony?	yes  no   (R)
If yes, please describe:
Have you ever been professionally disciplined?	yes  no   (R)
If yes, please describe:
Your additional comments:
I verify the accuracy of all my provided information:	yes  no   (R)
Verification (to make sure you're human) Enter the text you see in image (or refresh for new text)
Note: Please do not include any URLs in form.

Thanks very much for your application!

Jim Melamed,
CEO Mediate.com
admin@mediate.com