The Supreme Court of Ohio
& The Ohio Judicial System

Directory of Foreclosure Mediators Sign-Up Form

The purpose of this form is to collect foreclosure mediation resource information to populate a Directory of Foreclosure Mediators for the general public and courts to use to hire mediators and to facilitate the dissemination of foreclosure mediation information and resources.

All individuals self-report training and other qualifications. It is recommended that individuals verify respective local court required and preferred qualifications before assigning cases. Inclusion on this list does not imply an endorsement by the Supreme Court of Ohio.

View the complete directory of foreclosure mediators.

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NOTE: All fields on this form are REQUIRED.
Last Name:
First Name:
Organization:
Address:
City:
State:
Zip Code:
Telephone:	(123) 456-7890
E-mail:
I have successfully completed all of the following trainings: 1) Basic Mediation (minimum of 12 hours), 2) Foreclosure Mediation offered by the Supreme Court of Ohio and 3) the Uniform Mediation Act (minimum of two hours).	Yes No
Are you an attorney licensed in the state of Ohio?	Yes No
Are you currently taking cases?	Yes No
What counties are you willing to serve? (To make multiple selections, hold down the Ctrl key while making your selection.)	Select all that apply Adams Allen Ashland Ashtabula Athens Auglaize Belmont Brown Butler Carroll Champaign Clark Clermont Clinton Columbiana Coshocton Crawford Cuyahoga Darke Defiance Delaware Erie Fairfield Fayette Franklin Fulton Gallia Geauga Greene Guernsey Hamilton Hancock Hardin Harrison Henry Highland Hocking Holmes Huron Jackson Jefferson Knox Lake Lawrence Licking Logan Lorain Lucas Madison Mahoning Marion Medina Meigs Mercer Miami Monroe Montgomery Morgan Morrow Muskingum Noble Ottawa Paulding Perry Pickaway Pike Portage Preble Putnam Richland Ross Sandusky Scioto Seneca Shelby Stark Summit Trumbull Tuscarawas Union Van Wert Vinton Warren Washington Wayne Williams Wood Wyandot
General Comments:
I certify and affirm that the facts contained. on this form are true, accurate and valid and thereby authorize the Dispute Resolution Section to share this information where appropriate.	Yes No
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