522.pdf

Please be advised:

Mediator applications will only be accepted during the time that the Division has an open solicitation.

********currently there is no open solicitation********

Revised 4/16/2018 Page 1 of 2 Form 522

STATE OF NEVADA

DEPARTMENT OF BUSINESS AND INDUSTRY - REAL ESTATE DIVISION

OFFICE OF THE OMBUDSMAN FOR COMMON-INTEREST COMMUNITIES AND CONDOMINIUM HOTELS

3300 West Sahara Avenue, Suite 350 * Las Vegas, NV 89102

(702) 486-4480 * Toll free: (877) 829-9907 * Fax: (702) 486-4520

E-mail: CICOmbudsman@red.nv.gov http://red.nv.gov

ALTERNATIVE DISPUTE RESOLUTION

MEDIATOR APPLICATION FORM

(Please Print or Type)

Name: ____________________________________________________________________________________

Address: __________________________________________________________________________________

City: ____________________________________ State: _________________ Zip: ______________________

Email address: _____________________________________________________________________________

Daytime number: ______________________ Fax: ______________________ Cell: ______________________

NEVADA BAR ID# _____________________ Current Member Status: _____________________________

Must be in good standing

Profession: ________________________________________________________________________________

Professional Certificates / Designations: _________________________________________________________

Qualifications:

List Mediation format training/certifications. Include copies of any Certified Mediator certificates with the application.

Course/Training Titles:_______________________________________________________________________

Date(s): __________________________________ Number of Hours: _________________________________

Provider Name/Address: _____________________________________________________________________

Completion Validation: ______________________________________________________________________

(Attach additional training if applicable)

Name of Mediation/Arbitration organization or service:

Address: __________________________________________________________________________________

City: _______________________ State: ________________ Zip: ______________________

Phone: _____________________________________ Member Since: _________________________________ mailto:CICOmbudsman@red.nv.gov http://red.nv.gov/

Revised 4/16/2018 Page 2 of 2 Form 522

Please describe any experience with the mediation of homeowner association disputes. If no experience, please enter N/A:

Geographic Service Area:

☐ Reno/Carson/Tahoe Area

☐ Northeastern Nevada

☐ Central Nevada

☐ Greater Las Vegas Area

Please list foreign languages, or sign language, in which you have sufficient fluency to serve as a neutral:

Fee and Expenses:

_____________ Hourly Rate: $167 per hour.

_____________ Should I be appointed to the ADR Mediation panel, I acknowledge that as per NRS 38.330(2), all mediations are to be conducted at the maximum rate of $500 for no more than (3) hours. Any additional mediation time must be agreed upon by all parties involved, and the rate of this additional this is to be no more $200.00 per hour.

_____________ I acknowledge that Mediation proceedings may be subsidized by the Division as per NAC 116.520 in an amount not to exceed $500 or $250 for each party who is eligible for subsidy, whichever is less; and that I am not an employee of the State of Nevada, and therefore, I am eligible to receive subsidy payments from the State.

_____________ I CERTIFY that the above information and any other information I am submitting for this application is true and correct to the best of my knowledge and that I may be removed from the

Mediation panel or the approved Division Neutral List for intentionally falsifying the information provided. False certification may also subject me to civil or criminal penalties. I understand that all of the information provided is a public record. I agree to comply with all provisions of NRS

Chapter 38.

_____________ If I am listed on the Division Neutral List, I agree to perform resolution services to the best of my ability in an ethical and proper manner and in accordance with the time provisions of the Mediation process.

______________ I acknowledge that unless otherwise agreed to by the parties, the mediator is appointed on a rotating basis within the discretion of the Division.

Signature Print Name Date

STATE OF ____________________________ ___ ss. COUNTY OF ___________________________________

I certify that this is a true and correct copy of a document in the possession of ________________________________

PRINT NAME

Notary Signature Commission Expiration: