Application for Mentorship

PART I: General Information

First Name *

Last Name *

Phone *

Certificate Number

Middle Name *

Business Name (If different from Name) *

Email address *

Date of Application

PART II: Certified Training

Have you attended a certified half day course related to “Mentoring Individuals seeking qualified Mediator status

Date of Training

Location of Training

Please attach either the original or a photocopy of your course completion certificate

Choose File

PART III: Mediation Experience

Year you became Certified as a Professional mediator

Attach evidence of having completed 10 cases and 30 hours of mediation at the level for which Mentor status is sought. (State only types of cases not names of parties)

Choose File

PART IV: Mentor Responsibilities

What is your understanding of the obligations and responsibilities of a Mentor in preparing and evaluating a mentee?

I hereby certify that the information provided in this application is true to the best of my knowledge and accurately reflects my qualifications to provide mentorship services incases My signature on any mentorship form(s) certifies that I have personally mentored and evaluated the applicant seeking to offer mediation to the public

Agree

If approved for Mentor status, I agree to adhere to the Standards of Ethics and Professional Responsibility for Mediators and mentors, adopted by Mediation Training Institute International East Africa. I understand that all information herein is subject to verification.

Agree

Mediation Training Institute International East Africa Jeevan Bharati Building 5th floor P.O Box 42199-00100 Nairobi [email protected] If you have any questions or comments, please contact our secretariat

Thank you for submitting your application.

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