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Alternative Dispute Resolution (ADR) Mediator/Arbitrator Acceptance & Conflict Disclosure
Case Name
(Required)
Case Number
(Required)
Type of Prceeding
(Required)
Mediation
Arbitration
Date of Appointment
Month
Day
Year
Mediator/Arbitrator
APPOINTMENT
I accept the appointment in this matter and confirm that I have reviewed the case information provided to me. I agree to conduct the mediation/arbitration in accordance with the Lancaster Bar Association ADR Program, Overview & Guidelines, Code of Eithics, and applicable professional standards.
CONFLICT DISCLOSURE
Please check one.
I have no actual or potential conflict of interest and am not aware of any circumstance that would reasonably call my impartiality into question.
I have a conflict or potential conflict to disclose.
I decline the appointment
Please describe any conflict or potential conflict.
Please list your reason for declining, if applicable.
CERTIFICATION
I understand that I have a continuing obligation to disclose any actual or potential conflict of interest that arises during the mediation or arbitration. I will promptly notify the LBA and the parties if circumstances arise that may affect my ability to remain impartial. I certify that the information provided above is true and complete to the best of my knowledge.
Name
First
Last
Date
Month
Day
Year
Email
Phone
