Certification Application

Name

first last

Email

Mediate.com Member #:

Confirm you are already a Mediate.com Certified Mediator or the equivalent:

yes
no

(Required)

Confirm you have provided complete information in your Mediate.com directory record:

college & graduate degrees
professional background
credentials and affiliations
trainings listed
mediation practice & approach
mediation fees
recent picture

(R)

Confirm that you have completed a 20 hour Mediating Online course

yes
no

(R)

Confirm you will verify 12 hours of provided annual online mediation continuing education:

yes
no

(R)

Have you ever been convicted of a felony?

yes
no

(R)

If yes, please describe:

Have you ever been professionally disciplined?

yes
no

(R)

If yes, please describe:

Your additional comments:

I verify the accuracy of all my provided information:

yes
no

(R)

I will update my provided information as reasonably necessary to keep current

yes
no

(R)

Verification (to make sure you're human)

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Note: Please do not include any URLs in form.