* Required Fields
Social Security Number:
Last four (4) digits only.
My phone number, fax number, or e-mail address has changed.
Business Name and Address:
1. Have you changed your employer?
If yes, please provide the start and end dates of the old employment and the new employment.
2. Please list any new arbitrator, mediator, or other dispute resolution-related training. Please do
not include arbitrator training provided by the Office of Dispute Resolution.
3. Has your professional practice or client base changed substantially?
If yes, are you now, or within the past three (3) years have you been:
associated with a member or other broker/dealer, municipal securities broker/dealer, or government securities broker/dealer?
registered under the Commodity Exchange Act?
a member of a commodities exchange or a registered futures association?
associated with a person or firm registered under the Commodity Exchange Act.?
retired from engaging in any of the business activities listed (in a, b, c, or d) above but continuing to receive benefits from such activities? If yes, how many years have you been retired?
an attorney, accountant, or other professional who has devoted 20 percent or more of your professional work, in the last two years, to clients who are engaged in any of the business activities listed in a, b, c, or d above?
an employee of a bank or other financial institution who effects transactions in securities, including government or municipal securities, and commodities futures or options, or supervises or monitors the compliance with the securities and commodities laws of employees who engage in such activities?
the spouse or an immediate family member of a person who is engaged in the conduct or activities described in a, b, c, d, e, f, or g above or is retired and receiving benefits? (An immediate family member is a family member who shares a home with a person engaged in the conduct or activities described in a, b, c, d, e, f, or g above; or is a person who receives financial support of more than 50 percent of his or her annual income from a person engaged in the conduct or activities described in a, b, c, d, e, f, or g above; or is a person who is claimed as a dependent for federal income tax purposes by a person engaged in the conduct or activities described in a, b, c, d, e, f, or g above.)
an attorney, accountant, or other professional who has devoted 50 percent or more of you professional or business activities, within the last two years, to representing or advising public customers in matters relating to disputed securities or commodities transactions or similar matters?
none of the above categories apply.
If yes, please provide details:
4. Please inform us of any changes or new disclosures about clients, accounts, or conflicts.
5. Please add any new known conflicts and the nature of the conflict, for example, any brokerage firm where you or any member of your family has or had an account, or where any family member is or was employed.
6. Have you ever been named as a party by an investor in any civil lawsuit or arbitration proceedings?
If yes, please explain:
7. Please include any other information you would like to update. (For example, the date of opening or closing any brokerage firm account for you or any immediate member of your family, new clients, etc.).
8. Please update the total number of cases you have mediated.
9. Please update your current settlement rate. %
10. For the cases where you served as mediator, please update the breakdown by subject matter of the percentages of each type of case you mediated. (The total of all seven categories combined should equal 100%):
11. Please provide any updates to your mediator rate $ per (indicate if it's per hour, per day or a flat rate per mediation).
12. To edit or update the narrative summary of your background, check the appropriate item below. We will send you an electronic file that you may correct or update and send back to us. Please be sure to include any explanations about how you charge expenses in your narrative.
Yes, please send my Narrative Summary to the e-mail address above.
No, I do not have any changes to my Narrative Summary at this time.
13. To have us email a copy of your entire mediator profile, please check the item below. We will send you a pdf file that you can review. To update your profile, please use the form above to indicate the changes you would like.
Yes, please email a pdf version of my mediator profile for my review at the email address above.
No, I do not wish to review my entire mediator profile at this time.