IAM Mentorship Program Application - International Academy of Mediators

Mentee Information

Name*

D.O.B*

Address*

City*

State*

ZIP*

Country*

Email*

Phone*

Fax*

Please attach your curriculum vitae.*

Drop files here or

Max. file size: 512 MB.

MMP Sponsor (must be an IAM Distinguished Fellow) (Please attach a letter from your sponsor.)*

Drop files here or

Max. file size: 512 MB.

Name of your sponsor*

In what capacity do you know your sponsor?*

How long have you known your sponsor?*

IAM Fellows. Please identify any IAM members you know.*

IAM Conference Attendance

Have you attended an IAM Conference?*

Yes
No

Please provide the place and date*

Mediation Experience, Training, Teaching and Publications

How many days have you served as a mediator for compensation in commercial disputes?

In the past 12 months*

In the past 3 years*

(Commercial disputes exclude political, public policy, residential landlord/tenant, family, and community matters. A day is at least 4-6 hours or more, including preparation time.)

What mediation training have you attended as a participant?*

What articles or books have you published regarding mediation?*

What is your experience teaching mediation? Provide course titles, institution, and dates.*

References

Please list four references IAM may contact. References should be counsel, parties, or party representatives with whom you have worked in a mediation session in the past year.

Name/Address/Phone/Email*

Background

Have you ever been convicted of or are charges pending regarding a violation of any criminal law (other than minor traffic offenses), ethical, code of conduct, or disciplinary rules of any state government or provincial agency, bar association or private or public professional entity?

Convections*

Yes
No

Convections Explain*

Personal Statement

Describe why you would like to be considered for the Mediators’ Mentorship Program.*

List three goals you seek to achieve through your participation in the Mediators’ Mentorship Program.*

Identify how you plan to work with your sponsor to further your knowledge, experience and practice and achieve the goals set forth in your response to question 9.b above.*

Consent*

• I affirm and verify that I have read and understand the preceding questions, and that the answers are true and complete to the best of my knowledge, information and belief. I understand that all information submitted is subject to independent verification. I understand that my submission of this information does not create any obligation on the part of the International Academy of Mediators to admit me into the Mediators’ Mentorship Program. I also understand and accept that if, in the opinion of the members of the MMP Committee or the Board of Governors, I violate the Constitution and/or By-laws, the IAM Sexual Harassment Policy, or fail to meet the requirements of the Mediators’ Mentorship Program, the

International Academy of Mediators has the right to terminate my participation in the Program and all rights deriving therefrom. I further understand and agree that the IAM Board of Governors may terminate my participation in the Program, or may terminate the Program itself, at any time and for any or no reason.
• I affirm that I will adhere to the meeting requirement to attend at least one Academy conference every year and complete any mandatory continuing educational requirements established by the Academy. I further understand that the Mediators’ Mentorship Program requires a two-year commitment by both the Mentor and the Mentee and that the MMP is
not a guarantee of membership in the IAM.
• I understand that the International Academy of Mediators is not a case administrating entity.
• I understand that the IAM may decline or delay action on my nomination for reasons of membership size, geographical diversity or other appropriate considerations.

Affirmation

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IAM Mentorship Program

Mentee Information

IAM Conference Attendance

Mediation Experience, Training, Teaching and Publications

References

Background

Personal Statement

Mediator’s Mentorship Program Committee Contact Information

CHAIR:

COMMITTEE MEMBERS:

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