Name:  

  Mr. Mrs. Miss Ms. Dr.                     N/A Sr. Jr. I II III   

                          First: *                      Middle: *                    Last: *            Suffix: 

Name by which you wish to be addressed: *      

Number of years in dispute resolution field: *      

Contact Information:   

Company Name: 

Mailing Address:*   

City:*        State: *         

Zip Code: *    

Telephone: (at least one contact number is required)

Office:       

Cell:           

Fax:           

Home:     

Email address where you wish to receive correspondence from the NCAPFM: *

Website address:

Additional information:

What are your areas of mediation expertise? - Check all that apply*

Divorce (private practice)

AOC Custody/Visitation

FFS

Elder Care

Wills/Estates

Parent/Teen

Other areas of expertise not listed above:

Are you an attorney?*    Yes     No

If you are an attorney, what services do you offer?

Mediation

Litigation

Attorney led negotiations (no mediation)

Collaborative Divorce

Divorce filing

Other legal services offered:

What feedback can you provide the Leadership Team about your experiences this past year with the NCAPFM?  (What did you like/dislike?, What changes would you like to see?, What did you think of the programming?, Did you feel a part of the organization?, etc)

Would you like to use your talents on a committee?

Continuing Education - Plans and coordinates educational programs on topics of interest to members.

Hospitality - Coordinates refreshments and other supplies for programs or meetings.

Communications - Disseminates information about the association, its activities, and ADR to members.

Membership - New members, membership renewal, and list maintenance.

What is your membership category? *

General - for any individuals who are interested in or involved in family mediation

Practitioner - for those who meet one of the following criteria

                              (please indicate criteria met):

       Completed 40 hours of family mediation training approved by the ACR or the NCDRC and have been practicing for at least 3 years

       Custody and visitation mediator employed by the Administrative Office of the Court

       Family Financial Mediator certified through the NC Dispute Resolution Commission