Re-Certification Application

1. A certified mediator will verify attendance at IAM approved training (see Iowa Approved Trainers on website for list), and/or continuing mediation education workshops, conference or similar activities, totaling not less than six hours. The six hours shall include at least one hour in mediation ethics and one hour in domestic abuse and power imbalance issues. Up to 12 continuing education hours may be accumulated and applied to certification requirements in the following two years.

2. Request for IAM re-certification shall be accompanied by a yearly fee of $50 payable to IAM. This re-certification fee of $50 is due each January 1st. Any new payment of $50 will cover the fee until the following January 1st regardless of the date of the re-certification.

Name

first last

Title

Company

Address

	street line 1
	street line 2
,	city, state/prov zip

Phone

Fax

I have met the continuing education requirements discribed above

Yes
No

(Required)

Continuing Education Courses during the past year (include names and dates)

(R)

I continue to conform to all the requirements included in the IAM Certification Guidelines

Yes
No

(R)

Note: Please do not include any URLs in form.

Your payment of $50 is to accompany your application for re-certification. 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 for the following year.

This $50 re-certification fee is due before january 1 of each year along with your re-certification application 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 qualifications 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:

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Re-Certification Application