Personal Information

Full Name (Accredited Mediator): *
Name of Practice:
For invoicing purposes
Race: *
ID Number: *
Gender: *
Mobile Number: *
Address: *
    City: *
    Region: *
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    Website Address:
    Mediation Type: *
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    Professional Information

    Profession: *
    Are you an attorney, Dr, Engineer etc
    Professional registration authority: *
    EG: Law Society, HPCSA, etc
    Professional Registration Number:
    Mediation Specialty: *
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    Other:
    Please list Specialty
    Have you completed the required Training?:
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    Mediation Training Provider: *
    Training Certificate: *
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    Allowed file types: .*
    Min 40hr Training and Assessment
    Recognized Mediation Organization: *
    What association do you belong too?
    Membership No (if applicable):
    Certificate of Good Standing: *
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    Able to function as:: *
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    Years Accredited as a Mediator: *
    Number of completed Mediations: *
    Number of completed Mediations
    Years of Experience in RAF/Medico-legal matters: *
    Letter of Experience:
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    Please upload written proof of personal injury specific experience or training.
    Years of Experience in any medical matters: *
    Monthly Mediation Capacity: *
    How many matters can you handle per month?
    Language: *
    Other languages:

    Member Fee Structure

    Fee Per Hour:
    Financial administration: *
    The ADR TG offers the facility to manage the invoicing and collecting of fees, from the parties, on your behalf. We charge a 10% surcharge of all fees invoiced for this service.
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