Mediator Information Update Form

It is essential that the information the Office of Dispute Resolution provides to parties regarding the mediators on our roster be accurate and up-to-date. For this reason, mediators have a continuing obligation to update the roster information that we maintain on their behalf.

Accordingly, if you are a mediator on our roster, please use the following form to notify us of any new or revised information. Please be sure to add any recent changes to your business and/or home address and other contact information.

NOTE: If you have already registered with the DR Portal, please log in and make any updates to your profile using the portal.

* Required Fields Mr.         Mrs.       Ms.
First Name:*
Last Name:*
Arbitrator/Mediator #:
Social Security Number:* XXX-XX- Last four (4) digits only.
  My phone number, fax number, or e-mail address has changed.
Business Name and Address:
  Use the above as my primary address.
If the above requires a change to your employer's Tax ID number
for purposes of your honorarium, please enter the new number:

Tax ID#:
Home Address:
  Use the above as my primary address.

1. Have you changed your employer?
Yes No
If yes, please provide the start and end dates of the old employment and the new employment.

  Employer Name Title From To
Old Employer:
New Employer: Present
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.
Session Date Session Name Session Provider
3. Has your professional practice or client base changed substantially?
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%):
Other Commercial/Business %
Insurance Claims%
Consumer Disputes%
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.

NOTE: Before you click "Submit Update", review your update to ensure that it is accurate and complete.