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| Salutation: |
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| First
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| Middle: |
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| Last
Name: |
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| Suffix: |
e.g.
Jr., III, PhD., LCSW, MD, (Ret), etc. |
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| MAILING
ADDRESS: |
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| Title
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| Organization |
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| Address: |
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| City: |
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| State: |
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| Zip
Code: |
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| County: |
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| Business
Phone: |
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| Fax
#: |
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| Email: |
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| Website
address: |
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| MEMBERSHIP
INFORMATION: |
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TAM
lists member addresses, telephone and e-mail on the
website. |
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I
do NOT want to be listed on the website |
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ANNUAL
DUES (TAM membership dues apply to the calendar year
in which you are joining. However, if you are joining
after October 1st, dues will be applied to the following
calendar year. Please check one.) |
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Full Member - $75 (An individual who
has satisfied the education, training and experience
requirements for full membership.)
Candidate for Membership- $45 (An individual
who has satisfied the education and training requirements
for membership, but lacks the necessary hours of experience.)
Friend of TAM- $50 (An individual or
organization that supports the mission of TAM. Friends
of TAM do not have to complete the training, education
and experience sections.) |
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| MEDIATION
TRAINING (Please check the mediation training that you
have completed.) |
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I
have completed a 40-Hour Basic Mediation Training Course.
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I have completed a 24-Hour Family Mediation
Training Course. (Required only if you are engaged in
family mediation.) |
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Note:
Documentation in the form of a copy of the certificates
for training, for both the 40-hour basic training and,
if applicable, the 24-hour family mediation training
must accompany the application for membership
form. If a certificate is not available, a
letter from the trainer stating successful completion
for the applicant will be acceptable. |
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| EDUCATION
(Please check one.) |
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I
have a graduate degree from an accredited college, university,
or law school.
I have an undergraduate degree from an accredited college
or university.
I am requesting a waiver of the education requirement
and I am submitting evidence of alternative qualifications
and/or exceptional commitment to and/or merit in the
field of mediation. Please contact the Membership Director
for more information and click here for factors that may be considered. |
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| PROFESSIONAL
WORK EXPERIENCE (Please check one.) |
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I
have had two (2) to four (4) years of professional work
experience in my field of practice.
I have had four (4) or more years of professional work
experience in my field of practice. |
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| MEDIATION
EXPERIENCE
(Please check one.) |
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I
have more than 100 hours of documented
mediation experience.
I have less than 100 hours of documented
mediation experience. |
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| DATE
AND SIGNATURE : |
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By
signing below, I certify that the foregoing information
is true and correct and that I have completed the training,
education and the hours/years of experience as I have
indicated above. |
| Date: |
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| Signature: |
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When
finished, please click the "Submit" button.
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