Attachment H - Application 522.pdf

STATE OF NEVADA

DEPARTMENT OF BUSINESS AND INDUSTRY - REAL ESTATE DIVISION

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

3300 W. Sahara Avenue, Suite 350, Las Vegas, NV 89102

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

CICOmbudsman@red.nv.gov http://red.nv.gov

Page 1 of 5 Form 522

ALTERNATIVE DISPUTE RESOLUTION

MEDIATOR APPLICATION FORM

(Please Print or Type)

Name:

Address:

City: State: Zip Code:

Daytime Number: Fax Number: Cell:

Email Address:

NEVADA BAR ID # (if applicable): Current Member Status (must be in good standing):

COMPANY/BUSINESS INFORMATION:

Company Name:

Address:

City: State: Zip Code:

Contact:

Phone Number: Fax Number:

Email Address:

CONTRACT INFORMATION: (Information listed here will appear on your contract)

State: Zip Code:

Fax Number:

Contractor Name:

Address:

City:

Contact:

Phone Number:

Email Address:

Profession:

Revised 4/27/2021 mailto:CICOmbudsman@red.nv.gov http://red.nv.gov/

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

3300 W. Sahara Avenue, Suite 350, Las Vegas, NV 89102

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

CICOmbudsman@red.nv.gov http://red.nv.gov

Revised 4/27/2021 Page 2 of 5 Form 522

Professional Certificates/Designations:

QUALIFICATIONS:

List Mediation training/certifications/re-certifications (continuing education). Include copies of certificates with the application.

Course/Training Title Date Hours Provider Name

Attach additional training if applicable.

Are you a member of a Mediation/Arbitration organization or service? Yes No

Name:

Address:

City: State: Zip Code:

Phone: Length of Membership with Service:

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

3300 W. Sahara Avenue, Suite 350, Las Vegas, NV 89102

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

CICOmbudsman@red.nv.gov http://red.nv.gov

Revised 4/27/2021 Page 3 of 5 Form 522

Please describe any experience with mediating disputes between parties in a professional capacity such as business, employment, insurance, real estate, and business dissolutions. Also describe any experience with the resolution of disputes concerning Homeowner Associations, including, and without limitation, the interpretation, application, and/or enforcement of the covenants; conditions and restrictions pertaining to residential property as well as the articles of incorporation, bylaws, and rules and regulations.

GEOGRAPHIC SERVICE AREA:

Reno/Carson/Tahoe Area Central Nevada Northeastern Nevada Greater Las Vegas Area

Please list foreign languages or sign languages and level of fluency:

QUESTIONNAIRE:

1. Are you presently employed by the State of Nevada, any of its political subdivisions, or by any government agency?

Yes No

If yes, please explain and list agency/department:

2. Were you formerly employed by the State of Nevada within the last 24 months? Yes No

If yes, please explain and list agency/department:

3. Have you been engaged under contract by any State Agency? Yes No

If yes, please explain and list agency/department:

4. Are you presently involved in any litigation with the State of Nevada? Yes No

If yes, please explain and list agency/department:

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

3300 W. Sahara Avenue, Suite 350, Las Vegas, NV 89102

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

CICOmbudsman@red.nv.gov http://red.nv.gov

Revised 4/27/2021 Page 4 of 5 Form 522

All applicants MUST complete this section.

INSURANCE:

Workers Compensation

Affidavit of Rejection of Industrial Insurance Coverage OR

Insurance Certificate - Expiration Date:

Commercial Liability

Insurance Certificate - Expiration Date:

Professional Liability/Errors and Omissions Liability

Insurance Certificate - Expiration Date:

NEVADAEPRO:

Are you registered with the State of Nevada’s electronic procurement system, NevadaEPro? Yes No

My NevadaEPro Vendor ID number is:

NevadaEPro registration is required. Vendors must be registered in NevadaEPro to respond to bid solicitations posted by the State of Nevada. NevadaEPro is available to register your company to receive future solicitation notifications, respond to solicitations, provide quotes, and receive purchase orders or contracts. Go to https://nevadaepro.com.

Please direct questions from the NevadaEPro registration to State Purchasing at https://nevadaepro.com. State

Purchasing can be contacted at (775) 684-0170 or nevadaepro@admin.nv.gov.

NEVADA STATE CONTROLLER’S OFFICE – DATA WAREHOUSE OF NEVADA (DAWN):

Are you registered with DAWN? Yes No

My Nevada State Controller’s Vendor number is:

All vendors receiving payment from a State agency must complete a State of Nevada Vendor Registration form per IRS compliance. This record will be used by all State agencies to make payments to you.

You can contact Vendor services at (702) 486-3895 or vendordesk@controller.state.nv.us.

State Registration Vendor Information must be consistent.

Does your company name and address match in NevadaEPro, in DAWN, and on the contract? Yes No

If there are inconsistencies, please explain:

mailto:CICOmbudsman@red.nv.gov http://red.nv.gov/ https://nevadaepro.com/ https://nevadaepro.com/ mailto:nevadaepro@admin.nv.gov mailto:vendordesk@controller.state.nv.us

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

3300 W. Sahara Avenue, Suite 350, Las Vegas, NV 89102

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

CICOmbudsman@red.nv.gov http://red.nv.gov

Revised 4/27/2021 Page 5 of 5 Form 522

NEVADA SECRETARY OF STATE:

Are you registered with the Nevada Secretary of State? Yes No

Legal Entity Type:

NV Corporation (Domestic Corporation)

LLC

LLLP

Other

Foreign Corporation

LP

Sole Proprietor

Non-Profit Corporation

LLP

Governmental Entity

If Other, please list entity type or explain:

Is the legal entity active and in good standing with the Nevada Secretary of State’s Office? Yes No

Do you have a current Nevada business license number assigned by the Nevada Secretary of State? Yes No

My Nevada business license number is:

Do you have a current Certificate of Business (Fictitious Firm Name)? Yes No

My FFN Instrument Number is:

List Other Relevant Business Licenses and Business License Numbers:

APPLICANT DECLARATION:

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 for intentionally falsifying the information provided. False certification may also subject me to civil or criminal penalties. I understand that all the information provided is a public record. I agree to comply with all provisions of NRS Chapter 38.

INITIAL

State of SS. COUNTY OF

This instrument was acknowledged before me on (date) , in the possession of applicant (Notary prints the name of the person who presents the document) .

(Notary Stamp) Signature of Notarial Officer mailto:CICOmbudsman@red.nv.gov http://red.nv.gov/