P a g e | 7 of 7 Mediator Application Form
I hereby certify that I have reviewed and, if selected, will comply with the Oregon Revised
Statutes, Uniform Trial Court Rules, and Supplemental Local Rules for Multnomah
County that pertain to civil case mediation. I affirm that I have reviewed the August
2005, Chief Justice Order No. 05-028, describing the Oregon Judicial Department Court-
Connected Mediator Qualifications Rules and that the above information is a true and
accurate reflection of my qualifications as a mediator as outlined in that CJO. I
acknowledge that my information may be verified, and that any references and/or
programs listed above may be contacted. I expressly approve such investigation, and
consent to the release of information about me from any relevant source. I agree to fulfill
the continuing education requirement for court-connected mediators [Section 2.1(3),
2.2(4), 2.3(4), & 3.6] and all other requirements specified in the CJO. I will keep the court
informed of any changes in my contact information, license status, or qualifications to be
listed as a mediator.
Sign with an electronic signature per UTCR 21.090(2)
INSTRUCTIONS FOR SUBMITTING COMPLETED FORM
After the form has been completed, click the button bellow to e-mail this PDF form to the court.
If you don’t have the ability to e-mail using the button below, you will need to save
the PDF to your computer, then e-mail it manually as an attachment to:
Retain a copy for your records if you desire. Having this form saved to your computer will expedite your ability to
update information as required by the CJO.
Questions? Call the mediation coordinator at 503-988-3318 or e-mail email@example.com
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