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Membership > Certification Application

 

Application for Mediator Certification

(Members Only)

Name
first last
Title
Company
Address
street line 1
street line 2
, city, state/prov zip
Email
Phone
Fax
Relevant Experience and Educational Background (include degrees and dates) (Required)
Mediation Training Appropriate for Level of Certification (include dates and trainers) (R)
Fields of Practice
Family/Divorce
General
Community
Victim-Offender
Workplace
Civil
Personal Injury
Commercial
Farmer/Creditor
Child Welfare
Civil Rights
Truancy
Public Policy
Organizational
School-Based
EEOC/Postal Service
Elder
Small Claims
Real Estate
Mortgage Foreclosure
   (R)
I promise to adhere to the IAM Model Standards of Conduct for Mediators
Yes
No
   (R)
I promise to adhere to the IAM Guidelines for Certification of Mediators (this document)
Yes
No
   (R)
References (R)
I agree to take part in at least 6 hrs/Year of continuing education related to my stated field of practice
Yes
No
   (R)
I agree to maintain appropriate practice documentation and malpractice insurance
Yes
No
   (R)
I have met the Observation and Co-Mediation Requirements of my field of practice
Yes
No
   (R)

Note: Please do not include any URLs in form.

Your payment of $50 is to accompany your application.  This annual fee is not-refundable and receipt is not contingent upon the approval or disapproval of your application by IAM.  This fee covers your IAM Certification listing through December 31 of the year in which you make application.

A $50 re-certification fee is due before january 1 of each year along with your re-certification applications assuring continued compliance with IAM Certification Requirements.

IAM does not vouch for your qualifications as a mediator or your compliance with these requirements but only informs the public of your assertions of qualification and compliance so that they may make more informed choices.  Since IAM is unable to verify your information or monitor your practice, IAM and the public rely upon your truthfulness and integrity.

IAM considers the submission of this form along with payment of your certification as your acceptance of these understandings.

You may either pay by credit card below or send your check payable to the Iowa Association of Mediators to:

A.M. Fink, IAM Treasuer - 222 South Russell - Ames, IA 50010