1. NAME: _____________________________________________________________________

OFFICE
ADDRESS: __________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

TELEPHONE:__________________________ FAX: ______________________________

• ARE YOU AN ATTORNEY: Yes __________ No__________

• DATE ADMITTED TO NEW YORK STATE BAR __________________________________

• DATE ADMITTED TO PRACTICE BEFORE THE NORTHERN DISTRICT OF NEW YORK:______________________________________ BAR ROLL #____________________

• DATE ADMITTED TO PRACTICE BEFORE THE HIGHEST COURT OF A STATE (other than New York):_______________________________________________________________

 
• COURT:_____________________________________________________________________

• DATE OF ADMISSION:________________________________________________________

• SET FORTH BRIEFLY IN CHRONOLOGICAL ORDER, WITH DATES, THE NATURE OF YOUR PRACTICE OF LAW SINCE ADMISSION TO THE BAR.

• ARE YOU PRESENTLY ENGAGED IN THE ACTIVE PRACTICE OF LAW IN THE NORTHERN DISTRICT OF NEW YORK? Yes__________ No_____________

 

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

• STATE BRIEFLY THE NATURE OF YOUR PRESENT PRACTICE:

• WHICH OF THE FOLLOWING BEST DESCRIBES YOUR PRESENT PRACTICE OF LAW?

__________ My practice primarily consists of representing debtors.

__________ My practice primarily consists of representing creditors.

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

• PLEASE LIST THE NAME(S) OF JUDGE(S) (including bankruptcy and magistrate judges) BEFORE WHOM YOU HAVE APPEARED OR WHO OTHERWISE MAY HAVE KNOWLEDGE OF YOUR QUALIFICATIONS.

• IF YOU HAVE NOT NAMED ANY JUDGE OF THIS COURT IN ANSWER TO QUESTION #9, PLEASE LIST ANY OTHER FEDERAL JUDGES OR STATE JUDGES BEFORE WHOM YOU HAVE APPEARED WHO MAY OTHERWISE HAVE KNOWLEDGE OF YOUR QUALIFICATIONS.

• HAVE YOU EVER REPRESENTED A PARTY IN A CASE THAT WENT TO ANY FORM OF ALTERNATIVE DISPUTE RESOLUTION (ADR)? If yes, please state where, when, type of court and type of ADR forum.

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

• HAVE YOU EVER SERVED AS A MEDIATOR IN THE FEDERAL COURT SYSTEM? If yes, please state where and when.

• HAVE YOU EVER SERVED AS A MEDIATOR IN ANY STATE COURT? If yes, please state where and when.

• WOULD YOU BE INTERESTED IN PARTICIPATING IN A MEDIATION TRAINING PROGRAM SPONSORED BY THE COURT?

• PLEASE SET FORTH ANY ADDITIONAL INFORMATION YOU BELIEVE WOULD BEAR UPON YOUR QUALIFICATIONS TO SERVE AS A MEDIATOR.

• PLEASE CHECK THE DIVISIONS WHERE YOU WOULD PREFER TO SIT AS MEDIATOR.

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

SIGNATURE:________________________________________________________________

DATE:______________________________________________________________________
 
 

NOTE: Please complete the attached request forbiographical data.