OASIS ALLIANCE CORP.

Mediator Application
Residential Mortgage Foreclosure Mediation

First Name		Middle Initial		Last Name
Mail Address				Email Address
Mail Address Cont .			Tel.	Office
City				Home
State				Mobile
Zip Code			Fax
			Other
Taxpayer Identification Number (TIN) Enter your payment information and TIN below. The TIN provided must match the name given. For individuals, this is your social security number (SSN). For other entities, it is your employer identification number (EIN). If payments are to be made to YOU, enter your name below (as shown on your income tax return) and provide your social security number.
Name				Social Security Number
If payments are to be made to YOUR COMPANY, enter the business name below and provide the employer identification number.
Business Name				Employer Identification Number
Address (number, street, appt or suite no)
City, State and ZIP Code
PROFESSIONAL Mediator Certifications
Certificates				Education Degree	Institution
Circuit Civil Year Certified			College
Ceritification Number			Law/Graduate
	CME credits for current reporting cycle		Completed
			To be Completed
Do you have a certificate of attendance at a special Residential Mortgage Foreclosure Mediation training program? Please email it to mediator@foreclosureoasis.org
Yes		No
Name fo training entity
Date of completion of course
If no, pending/planned attendance
Briefly describe your prior experience that supports your selection as a mediator in the RMFM program:

LANGUAGES SPOKEN

DISCLOSURE AND ETHICS Please disclose any direct or indirect financial ties to Lenders or mortgage loan servicers that you or your immediate family members have with any lenders, financial institutions and mortgage loan servicers (i.e. employment, consultancy, vendor relationships, etc.). There is an on-going duty to disclose such information during your participation as a mediator for the RMFM Program and should such circumstances change from your disclosures below, you should immediately notify the Program Manager.

Please describe any past or pending matters you were/are a party to regarding ethics matters, dishonesty, criminal matters, disbarment, suspension and/or expulsion from a professional organization or similar matters.

Are you familiar with and do you agree to comply with (Type word Yes next to each listed item you agree to comply with)
	1) Florida Supreme Court AOSC09-54
	2) Rule 10, Florida Rules of Court, including
	3) part II, Standards of Professional Conduct
	4) Sections 44.401-44.406 of Chapter 44 of Florida Statutes (Mediation Confidentiality and Privilege Act)
	Civil Procedures Rules 1.700, including Rule 1.730
SCHEDULING AND ELECTRONIC TRANSMISSION OF INFORMATION
Oasis Alliance, Corp., as Program Manager for the Fifth and Eleventh Judicial Circuit’s Residential Mortgage Foreclosure Mediation Program, plans to utilize electronic methods, including a secure internet web site, for the transmission of confidential information related to mediation and email communications for certain non-confidential transmissions to mediators regarding scheduling, etc. Do you have computer equipment and internet capability that will permit you to participate in such exchange of information and are you willing to so participate?
Yes		No
The Fifth Judicial Circuit consists of Citrus, Hernando, Lake, Marion and Sumter counties; the Eleventh Judicial Circuit consists of Miami-Dade county. Mediations will take place at Oasis designated venues within these counties. Multiple mediations may be scheduled during the same day. Oasis will require that mediators indicate their availability for full-day time commitments. A rotation scheduling system will be employed. Please indicate in which counties you are prepared to conduct mediations.
	Citrus
	Hernando
	Lake
	Marion
	Sumter
	Miami-Dade
Indicate the amount of time you would like to make yourself available to participate in the RMFM Program:
	Full-time (I plan to make myself available as much as possible to the RMFM Program)
	Part-time (I plan to split my time with other business interests)
	Limited basis (I only plan to participate a few hours a month)
With proper notice, will you be able to reserve an entire work day to provide mediation services to the RMFM Program?
Yes		No
Please submit a copy of your Circuit Civil training certificate and a copy of your certificate of attendance at the special Residential Mortgage Foreclosure Mediation Training to Oasis at Mediator@ForeclosureOasis.org or fax number 813.289.1555, Attn: Mediator Application Department. After reviewing applications, Oasis will notify mediators of their approval or non-approval for inclusion on its roster of foreclosure mediators and will provide a contract for those approved to execute. I acknowledge and agree that by providing my electronic signature to this Mediator Application I am affirmatively representing to Oasis that all information provided by me herein is true and completely accurate. I further acknowledge and agree that: (1) failure to provide true and completely accurate information in this Mediator Application and/or (2) any attempt to mislead, distort or provide erroneous information shall be immediate grounds for non-approval to serve as a mediator for Oasis Alliance, Corp in the RMFM Programs that it manages.
Electronic Signature
Thank you for your interest in serving as a mediator in the Fifth and Eleventh Judicial Circuit’s Residential Foreclosure Mediation Program.