Mediation PanelApplication

FIRST CLASS MEDIATION SERVICES THROUGHOUT ENGLAND AND WALES

MEDIATION

Full name, title and post nominal letters Current job title

Home address Professional address

Email Professional website address

Mobile Telephone

Professional qualifications

Mediation qualifications

Membership of professional bodies

Indemnity insurance (please provide copy insurance schedule, policy number and renewal date)

Mediation Panel Application Form

Insurance claims history

CPD record – please confirm a minimum of 6 hours in every 12 month period since qualification

Mediation experience (number of cases, hours of mediation, legal areas) – continue on an additional sheet if required

Areas of specialism (please tick all applicable)

Agriculture Building

Clinical Negligence Community

Company & Commercial Construction

Consumer Credit Contract

Debt (Business) Debt (Individual)

Education Employment

Family Insolvency (Company)

Financial Intellectual Property

Insolvency (Individual) Maritime

Landlord & Tenant Professional Negligence

Personal Injury Public Law

Property Other (please specify)

Taxation

Geographical areas covered (please tick all applicable)

Bedfordshire Greater London Oxfordshire Berkshire Gr Manchester Pembrokeshire Blaenau Gwent Gwynedd Powys Bridgend Hampshire Rhondda Cynon Taff Buckinghamshire Herefordshire Rutland Cambridgeshire Hertfordshire Shropshire Cardiff Isle of Anglesey Somerset Carmarthenshire Isle of Wight South Yorkshire Ceredigion Isles of Scilly Staffordshire Cheshire Kent Suffolk Cleveland Lancashire Surrey Conwy Leicestershire Swansea Cornwall Lincolnshire Torfaen County Durham Merseyside Tyne & Wear Cumbria Merthyr Tydfil Vale of Glamorgan Denbighshire Monmouthshire Warwickshire Derbyshire Neath Port Talbort West Midlands Devon Newport West Sussex Dorset Norfolk West Yorkshire East Riding of Yorkshire Northumberland Wiltshire East Sussex Northamptonshire Worcestershire Essex North Yorkshire Wrexham Flintshire Northern Ireland Gloucestershire Nottinghamshire

Languages spoken (i.e. languages in which you are comfortable conducting a mediation)

Notable cases as a lawyer

Biographical information (approx.. 500 words)

Brief testimonial quotes (for inclusion with biography – must be attributed)

Additional skills, education, training, experience or awards relevant to mediation or legal practice

Are you prepared to undertake pro bono mediation?

Kearns Legal Services

Brecon House

Caerphilly Business Park

Caerphilly

CF83 3GQ

T: 02920 808665

E: mediation@kearns.co.uk

| kearns.co.uk

MEDIATION