1. CONTACT INFORMATION
Name______________________________________________ Date _____________
Mailing address ________________________________________________________
Day phone __________ Eve phone ___________ Fax __________ E-Mail __________
Employer & Job Title (or Student Status) _____________________________________
Social Security # ____________________ (Needed for IRS paperwork)

2. BACKGROUND
Educational level & focus _________________________________________________
Mediation training (incl. no. of hours & from whom you received) ___________________
_____________________________________________________________________
Other volunteer experience ________________________________________________

3. REFERENCES
Please provide the names and contact information of two references we may contact: ____ ____________________________________________________________________
____________________________________________________________________

4. CMS MEDIATOR ABSTRACT FORM
Please complete the CMS Mediator Abstract form as part of this application. This form will help the mediation coordinator assign mediations.
The "comment" section at the top of the page is to help me in contacting you, e.g. some people want mediation notices sent to both office and home email addresses. Some mediators prefer not to be called at work except in an emergency such as unexpected cancellation of a session you were planning to mediate that day.
Roster Certifications: If you have had the additional training for DHHS, MHRC and/or USDA mediations or V/O conferencing, indicate by checking the appropriate box(es).
Types of Disputes - Mediator Interest and special Training/Skills/Experience: Check the box if you are interested in any of these types of mediations. In the comment section, identify any particular skills/training/experience in those or other related areas.

5. WHAT YOU BRING TO CMS
Please use the back of this page to describe (1) the qualities & skills you would bring to mediation and (2) why you are interested in volunteering for CMS. Return to:

Name: ________________________________________

Address: Telephone:
(h)
(w)
(cell)
(fax)
Email: Comments:
Alternate email:

ROSTER CERTIFICATIONS:
DHHS MHRC USDA Victim/Offender Conferencing Other _______________

AVAILABILITY - LOCATIONS
Counties you are willing to serve? Androscoggin Franklin Kennebec Knox
Lincoln Oxford Sagadahoc Somerset Waldo

AND/OR How far are you willing to travel? _________________________________________________________

AVAILABILITY - Day and Time: CMS schedules mediations in the morning, afternoon and evening depending upon the availability of the participants. Please describe your availability for CMS mediations.

TYPES OF DISPUTES - Mediator INTEREST and special TRAINING/SKILLS/EXPERIENCE

TYPE Check if INTERESTED COMMENTS: Please Identify any/all SPECIAL Skills/Training/Experience
in a particular type of mediation that would help us identify your strengths.
DHHS
Parent/Child
Family - other
Relationships
Discrimination
Landlord/Tenant
Neighborhood
Organizations
USDA/Agricul.
Victim-Offender
Workplace
Other: ______________________________________