Certification Application

Name

first last

Email

Mediate.com Member #:

Confirm you are already a Mediate.com Certified Mediator:

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 the 15 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.