Volunteer Mediation Information Form
Date Submitted: _______________
1. Name:_____________________________________________________________
2. Campus Address:
___________________________________________________
3. Day Time Phone: _______________ E-Mail Address: _________________________
4. Department:
_______________________ Job Title & Grade: ________________
5. How long in this position? ______years How long at UNM? ______ years
6. Supervisor Name & Title:
______________________________________________
7. Have you talked with him/her about your desire to be a member of the staff mediator pool?
Yes
_________ No _________
8. Supervisor’s Approval ________________________________ Yes
_____ No ______
Signature
9. Are you proficient in any languages other than
English? Yes____ No______
If yes,
which one(s)? _______________
10.
If you presently have a mediation
certificate, please attach a copy.
11.
Have you ever done formal mediations (for a
particular program or department)? Yes_____ No ________
If yes, please describe for
what program or department and approximately how many mediations you have done?
__________________________________________________________________________________
__________________________________________________________________________________