MC 281b (3/09) DOMESTIC RELATIONS MEDIATOR APPLICATION, Page 1 of 4
DOMESTIC RELATIONS MEDIATOR APPLICATION
To be eligible to serve as a domestic relations mediator, you must meet the training and experience criteria specified either
in MCR 3.216(G) or in the SCAO Mediation Training Standards and Procedures under MCR 3.216(G)(2).
Service as a case evaluator under MCR 2.403 does not constitute a qualification for serving as a mediator. Refer to the Mediation Training
Standards and Procedures for further information about minimum qualifications.
Note: Except for Part B, the information provided in this application is available to the public for inspection.
Please type or print neatly.
1. Full name (first, middle initial, last)
2. Bar no. if applicable
3. Address where you can be contacted
4. Telephone no.
5. Fax no.
6. E-mail address
Part A: Domestic Relations Mediator Qualifications Complete items 7 and 8, and either item 9, 10, or 11 as appropriate.
Is this a
renewal? If renewing, complete item 11 and attach a copy of your original application.
Completed a 4-hour domestic violence program approved by the State Court Administrative Office on
9. Qualification through State Court Administrative Office (SCAO)-Approved Training /
Association for Conflict Resolution (ACR) Training
a. SCAO/ACR-approved training completed on
. Attach copy of certificate.
If ACR training was completed more than 2 years before applying, the applicant must have completed 8 hours of advanced
mediation training in the 2 years before applying. Specify type of training, dates, and trainers, and attach copy of certificate.
Licensed in appropriate field. Specify.
Master or graduate degree in appropriate field. Attach copy of diploma.
5-years' experience in family counseling. Detail below. Complete on separate page if needed.
c. Observed two domestic relations mediation proceedings. Specify dates and mediator names and attach verificati