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(717) 393-0737
28 East Orange Street Lancaster, PA 17602

Alternative Dispute Resolution (ADR) Mediator/Arbitrator Application

APPLICANT INFORMATION

NOTE: A non-refundable application fee of $150 is required for each panel application and annual renewal. Applicants may select up to three (3) practice panels. Additional panels may be selected for an additional fee of $10 per panel.
Name(Required)
Business/ Professional Address(Required)
File must be less than 128 MB.
Drop files here or Accepted file types: pdf, docx, doc, jpg, gif, Max. file size: 128 MB.

    PANELS REQUESTED

    Please select all that apply:(Required)
    (Required)

    ELIGIBILITY

    Please check each requirement that applies.(Required)
    File must be less than 128 MB.
    Drop files here or Max. file size: 128 MB.

      BASIC MEDIATION TRAINING

      Please provide information about your required mediation training.
      Drop files here or Accepted file types: jpg, gif, png, pdf, Max. file size: 128 MB, Max. files: 3.

        If documentation is NOT available.
        File must be less than 128 MB.
        Drop files here or Accepted file types: jpg, gif, png, pdf, Max. file size: 128 MB, Max. files: 3.

          MEDIATION EXPERIENCE

          ARBITRATION QUALIFICATIONS

          (Complete if Applying for the Arbitration Panel)

          FAMILY LAW PANEL (if applicable)

          If applying for the Family Law panel, please identify your additional family law mediation and domestic violence training.

          PRACTICE AREAS

          Check all areas in which you are willing to mediate and/or arbitrate.
          Business
          Real Estate
          Family Law
          Litigation
          Other
          I am available to conduct mediation and/or arbitration by videoconference (Zoom or Microsoft Teams).(Required)

          DISCIPLINARY HISTORY

          Please identify and explain any disciplinary actions or proceedings against you in any jurisdiction within the last ten (10) years.(Required)

          CERTIFICATION

          I certify that the information in this application is true and correct to the best of my knowledge. I agree to promptly disclose any actual or potential conflict of interest that may affect my ability to serve as a neutral mediator or arbitrator. I have read and agree to comply with the LBA ADR Overview & Guidelines, Code of Ethics, and applicable ADR Program policies. I understand that the LBA may request additional information or documentation to verify my qualifications and that failure to meet the Program's requirements may result in denial of panel placement or removal from the panel.
          Signature
          Date