ARIAS·U.S. 
Application for Qualification as Mediator

(To fill out this form on your computer, replace the lines with your text, then print it out, sign it, and send to ARIAS•U.S.)

Personal Information

Name __________________________________________________ 
Home Address ___________________________________________
                       ____________________________________________
Home Telephone ________________ Home Fax ________________ 

Member in Good Standing of ARIAS•U.S.: Yes__ No __   If No, discontinue completion.

ARIAS•U.S. Certified Arbitrator: Yes__ No __   If No, discontinue completion.

Any Felony Convictions?: Yes__ No __ 
Explanation: ________________________________________________________ 
___________________________________________________________________ 
___________________________________________________________________ 

Undergraduate Education 
(School, Degree, Year of Graduation) 
___________________________________________________________________ 
___________________________________________________________________ 

Graduate/Professional Education 
(School, Degree, Year of Graduation) 
___________________________________________________________________ 
___________________________________________________________________ 

Professional Licenses/Credentials: _______________________________________ 
___________________________________________________________________ 

Current Employment 

Employer: ____________________________________________________
_____________________________________________________________ 
Title/Position Responsibility: _____________________________________________________________ 
Address: _____________________________________________________
_____________________________________________________________ 
Telephone: _____________________ Fax:_______________________
e-mail: ___________________________________________ 

Mediation Experience 

(Note: You must have successfully completed a mediation training program that requires a minimum of 35 hours of instruction, or provide information about other specialized experience in consensual dispute resolution that would indicate equivalence to that instruction, and is otherwise satisfactory to the Board of ARIAS•U.S. or its designee.)

1.  Name of Mediation Training Program (include certificate)______________________
     
      ____________________________________________________________________

	Location of Program ___________________________________________________
	Date Completed: _________________________ 
	Any Other Information _________________________________________________

2. Other Specialized Experience in Lieu of Formal Training Program
________________________________________________________________________ 
________________________________________________________________________________________________________________________________________________

Other Information 

You are invited but not required to offer any other information you feel should be brought to the attention of the Board of Directors of ARIAS•U.S. 

Statement by Applicant 

By signing and submitting this application to ARIAS•U.S., I agree to abide by and be subject to the ARIAS•U.S. Code of Conduct and the By-Laws of ARIAS•U.S., that the information contained herein may be verified by ARIAS•U.S. and that the information provided is accurate to the best of my knowledge and belief after taking reasonable steps to ensure its accuracy. 

_______________________________    ______________________________ 
Signature of Applicant 			Date Signed

Mail completed form to:

Sara Meier, Executive Director
ARIAS·U.S.
7918 Jones Branch Dr., Suite 300
McLean, VA 22102

Or Fax to 703-506-3266
Or (preferred) email PDF of signed application to certification@arias-us.org