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Location Phone Help Topics

Mediator Application

Mediator Application

Repeater

NAME(Required)

ATTORNEY REGISTRATION

FIRM NAME AND ADDRESS

TELEPHONE NUMBER(Required)

LAW SCHOOL ATTENDED if applicable

FAX NUMBER

EMAIL ADDRESS(Required)

DATE GRADUATED

MM slash DD slash YYYY

DATE ADMITTED TO PRACTICE IN OHIO

MM slash DD slash YYYY

PROFESSION IF NOT AN ATTORNEY

APPLICANT STATUS(Required)

New Applicant

Current Montgomery County Common Pleas Court Mediator

MEDIATOR TRAINING AND EDUCATION(Required)

No Prior Mediation Training or Education

Yes, I Have Prior Mediation Training and Education

If your answer is YES please summarize your mediation training education and certifications

MEDIATION EXPERIENCE

1. Approximately how many mediations have you participated in as a mediator in the past 3 years?(Required)

Approximately how many mediations have you participated in as counsel for one of the parties to the mediation in the past 3 years?(Required)

NUMBER OF APPOINTMENTS

Is there a maximum number of mediations per month you are willing to conduct?(Required)

Yes

No

If so, please specify

AREAS OF EXPERTISE

. What areas of the law do you believe you have special expertise due to your education, training and work experience? (i.e. personal injury, real estate, business law, etc.)

EXPERTISE 1

EXPERTISE 2

EXPERTISE 3

EXPERTISE 4

Are there any types of cases in which you would prefer not to be appointed as the mediator?(Required)

Yes

No

If yes, please list the types of cases:

Case 1

Case 2

Case 3

LOGISTICS

Do you have office space in order to hold in-person mediations?(Required)

Yes

No

Will you offer Zoom mediations?(Required)

Yes

No

If yes, can you moderate(Required)

Yes

No

Attorney Signature

Date

MM slash DD slash YYYY

Δ

Court Hours

Monday: 8:30am to 4:30pm
Tuesday: 8:30am to 4:30pm
Wednesday: 8:30am to 4:30pm
Thursday: 8:30am to 4:30pm
Friday: 8:30am to 4:30pm
Saturday & Sunday: Closed

Holiday Closure Schedule

Contact Information

Phone: 937-225-6000

Montgomery County Courts Building
41 N Perry St
Dayton, OH 45422

Reibold Building
14 W 4th St
Dayton, OH 45402

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