APPLICATION FOR ADMISSION TO MEDIATION OR VOLUNTARY ARBITRATION REGISTER

Form  110 A  Revised   11/12/04

I, the undersigned, hereby apply for inclusion on the Register of Mediators for the United States Bankruptcy Court for the District of Delaware.  In making this application, I certify under penalty of perjury that all of the following information is true and correct.
 
1. I will fully comply with the  relevant provisions of the Bankruptcy Code and Federal Rules of Bankruptcy Procedure and this Court’s relevant Local Rules and General Orders.
 
2.1
I have been licensed or accredited under the laws of the United States, Delaware, or any other state, in the professions or specialties listed below (e.g., attorney, accountant, real estate broker, appraiser, engineer, etc.) since the date indicated:
2.2
I am, or have been, a member in good standing of the professional organizations listed below which apply to my aforementioned professions: