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Account information

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Information

Title:

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First Name: *

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Middle Name: *

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Last Name: *

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Suffix:

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Nickname:

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Name of Organization: *

Name of Organization

Business Address 1: *

Your business address

Business Address 2:

City: *

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Telephone: *

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Cell Phone:

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Firm Website: *

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State Bar Admission Primary:

If you are not a licensed attorney, you must complete the three References fields below.

Other State Bar Admissions:

Other State Bar Admissions

Describe e-Discovery training :

Describe e-Discovery training (limit 250 words) (If you have no e-discovery training and would like to attend an ACESIN training, please check the box below)

E-Discovery Training

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Years in ADR: *

Years in ADR

Undergraduate Degree and Institution: *

Undergraduate Degree and Institution

Post-Graduate 1:

Post-Graduate Degree and Institution

Post-Graduate 2:

Post-Graduate Degree and Institution

Post-Graduate 3:

Post-Graduate Degree and Institution 3

Other specialized degrees and/or certifications:

Other specialized degrees and/or certifications

E-Mediations have you conducted?: *

How many e-Mediations have you conducted as the e-neutral? The content of this field is kept private and will not be shown publicly.

Special master appointments: *

How many special master appointments (or other court appointments) in e-discovery have you had? The content of this field is kept private and will not be shown publicly.

Experience:

Describe your E-mediation experience

References

Reference 1 Name:

Reference 1 Name (Required if you are not an attorney).

Reference 1 Address:

Reference 1 Address (Required if you are not an attorney).
Example: 123 street name, Suite 101, Birmingham, AL 12345

Reference 1 Phone:

Reference 1 Phone (Required if you are not an attorney).

Reference 1 Email:

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Reference 2 Name:

Reference 2 Name (Required if you are not an attorney).

Reference 2 Address:

Reference 2 Address (Required if you are not an attorney).
Example: 123 street name, Suite 101, Birmingham, AL 12345

Reference 2 Phone:

Reference 2 Phone (Required if you are not an attorney).

Reference 2 Email:

Reference 2 Email (Required if you are not an attorney).

Reference 3 Name:

Reference 3 Name (Required if you are not an attorney).

Reference 3 Address:

Reference 3 Address (Required if you are not an attorney).
Example: 123 street name, Suite 101, Birmingham, AL 12345

Reference 3 Phone:

Reference 3 Phone (Required if you are not an attorney).

Reference 3 Email:

Reference 3 Email (Required if you are not an attorney).

Terms

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I Agree (Required to be an ACESIN Fellow)

I acknowledge that my application will not be reviewed until ACESIN has received my $150.00 non-refundable application fee. If accepted as an ACESIN Fellow, I agree to pay ACESIN the annual membership fee based on the date of my application as follows:

January 1 to June 30: $700
July 1 to December 31: $550

The non-refundable application fee of $150.00 will be applied as a credit to the payment of the Fellow's annual memberhship fee in the first year of membership. Annual membership fees renew in January of the following year. (For example, if you apply in April of 2011, you will pay $150.00 non-refundable application fee. If you are accepted, you will pay a $700.00 minus the $150.00 application fee for a total of $550.00. In January of 2012, you will pay the 2012 membership fee.)
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