Mediator Application Form

Please fill out the following application. Contact with any questions.

Please fill out all information. *=required

Contact Information


Bar Admissions


ADR Experience


ADR Training


Legal Experience


Fee Structure



  1. been part of any civil, criminal or administrative proceeding charging you with conduct involving dishonesty, unethical conduct or commission of a crime? or
  2. been disciplined or cited for a breach of ethics or unprofessional conduct by any court, administrative agency, bar association, or other professional group, excluding sanctions in an amount less than $1,000, imposed against you in a civil proceeding?


U.S. Federal Court District of Kansas


U.S. Federal Court District of Kansas