FORM A - (11/02/98)
PART I
 
 

APPLICATION FOR APPOINTMENT AS MEDIATOR IN THE
UNITED STATES BANKRUPTCY COURT
NORTHERN DISTRICT OF NEW YORK

1. NAME: _____________________________________________________________________

OFFICE
ADDRESS: __________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

TELEPHONE:__________________________ FAX: ______________________________

If "No", please respond to items #12 thru #15 ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
 
 

FORM A - (11/02/98)
PART I con't.

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  CHECK ONE

__________ My practice primarily consists of representing debtors.

__________ My practice primarily consists of representing creditors.

__________ My practice cannot be designated as either of the above.
 

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__________________________ _______________________________

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__________________________ _______________________________

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FORM A - (11/02/98)
PART I con't.

Yes __________ No__________

____________________________________________________________________________

____________________________________________________________________________

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Yes__________ No__________

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Yes__________ No__________
 
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ALBANY_____ BINGHAMTON_____ SYRACUSE_____

UTICA_____ WATERTOWN_____







I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT.

SIGNATURE:________________________________________________________________

DATE:______________________________________________________________________
 
 

NOTE: Please complete the attached request forbiographical data.