Professional Mediation Association Membership Form

Membership Application Form

APPLICATION INSTRUCTIONS: Please answer the following questions in full in the space provided. Incomplete applications will be returned for further information. After you click the "Send Application" button, you will be forwarded to the payment information page to complete this application. We accept Visa/MasterCard through the free Pay Pal service.

You may also print this form and mail it to us with supporting documentation, application fee and dues payment to Professional Mediation Association. Please print this form BEFORE clicking the send button below if you need a copy of it or if you will be paying with a check.

Please enter your Login Username (4-8 characters, alpha or numeric) and Password below for further information update:

Username:
Password:

First Name:
Middle Name:
Last Name:
Title:
Organization:
Address:
City:
State:
Postal Code:
Phone:
Fax:
Email:
Web Address:

Please describe your sector(s) of practice: (Select all that apply.)

Arbitration	Commercial	Community	Consumer
Court ADR	Criminal Justice	Education	Employment
Environmental/ Public Policy	Family	HealthCare	International
Labor Management	Ombuds	Organizational Conflict Management	Training
Other Practices: (Describe briefly)

Please describe the neutral roles you perform: (Select all that apply.)

Administrator	Arbitrator	Attorney	Conciliator
Consultant	Educator	Facilitator	Judge
Mediator	Ombudsman	Researcher	Trainer
Other Roles: (Describe briefly)

	Here you can put your short resume:

Please indicate which type of membership you are applying for:

Professional Membership is $75.00 per year with a $25.00 application fee for board review. If the applicant is not approved for professional membership for any reason the applicant may receive a full refund of the Membership dues and the application fee.

Associate Membership is a free membership category which will allow membership but not allow referrals until upgraded to a Professional Membership.

Institutional or Corporate Membership is $75.00 per year with a $25.00 application review fee and entitles the member organization to receive newsletters, access online materials and may also designate one member of the organization to attend area and National Conferences. Institutional members also receive expedited attention in obtaining mediators for their organization or clients when needed.

Associate and Institutional Membership allows the use of "Member of the Professional Mediation Association" to be used and displayed by the Associate or the Organization member on printed material such as business cards, letterhead or other means of advertising.

Associate and Institutional Members do not receive client referrals. Referrals are only to qualified Professional Members.

You must Read and Agree to the Membership Agreement in order for your application to be considered.

I have read the Membership Agreement and agree to abide by its rules, terms and procedures.

Please verify that all information is correct then click the "Send Application" button below. Thank You.

The Professional Mediation Association
1645 Martha Leeville Road
Lebanon, TN 37090

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