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Registration Form

NATIONAL ASSOCIATION OF REALTORS Mediator/Mediation Training (available at http://www.realtor.org/mempolweb.nsf/pages/mediationtraining) The June 27, 28, and 29, 2012 seminar will be held at the NATIONAL ASSOCIATION OF REALTORS building in Chicago, 430 N. Michigan Avenue, on the second floor. Attendees must participate in all scheduled sessions. Although prior training and/or experience in mediating real estate related disputes is helpful, it is not necessary to have prior training/experience to attend. All are welcome. Please complete the enclosed attendee profile. Attendees (or their sponsoring organizations) are responsible for their transportation, lodging, meals (other than those provided by NAR), and incidental costs. Reservations must be made directly with the Courtyard by Marriott Magnificent Mile by calling 312-573-0800 or 800-321-2211. Please reference NARs Mediation Meeting to take advantage of the $169 per night room rate. Only the first fifty (50) registrations that are received will be accepted. Information provided immediately below used for attendee roster and to contact you regarding the program. (Please print or type)

Name: Address: City:


State:

Nickname (optional):

Zip:

Telephone: E-mail:

Fax:

Board or Association:

Please attach to your registration form a description of any disability requiring special services at this seminar. Completed registration forms must be accompanied by an attendee profile to optimize attendees learning experience, and can be sent to the Member Policy Department, NATIONAL ASSOCIATION OF REALTORS , 430 North Michigan Avenue, Chicago, Illinois 60611 (e-mail Bbarajas@realtors.org or fax to Bernice Barajas in the Member Policy Department at 312254-3188). Registration fee is $150 (nonrefundable after June 1). check enclosed, make payable to: NATIONAL ASSOCIATION OF REALTORS, account # 01-358-321 credit card payment: Visa MasterCard Credit Card # American Express Diners Club Exp. Date

Cardholder NRDS ID# (required)

Signature

Cardholder name and billing address (required)

Attendee Profile

NATIONAL ASSOCIATION OF REALTORS Mediator/Mediation Training (available at http://www.realtor.org/mempolweb.nsf/pages/mediationtraining) To optimize attendees learning experience, this form must be submitted with the registration form. Although prior formal training in mediation and/or practical experience in mediating disputes between REALTORS is helpful, prior training/experience is not required. All individuals affiliated with the REALTOR family are welcome to attend. Attendee information Name


Number of years as a sales licensee

Board or Association State Association

Number of years as a broker

Number of years as an association executive or staff specialist Other, please explain

Professional designations

Professional standards experience (approximate) Local Grievance Committee State Grievance Committee Local Board of Directors service State Board of Directors service Staff Mediation skills Formal training as a mediator Year Training provided by Hours of instruction # years # years # years # years # years

Local Professional Standards Committee State Professional Standards Committee NAR Professional Standards Committee Mediation officer Mediations conducted (how many)

# years # years # years # years #

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Practical (on the job) training as a mediator, including dates. Attach additional pages if necessary.


Summarize experience as a mediator conducting mediations over the past three (3) years. Attach additional pages if necessary.


Please describe your primary mediation style (e.g., facilitative, evaluative, other).

Other relevant training or experience.


Training experience Experience in personally conducting mediator training, if any, over the past three (3) years. Please describe training. Attach additional pages if necessary.


Briefly describe training programs (other than mediation training) that you have personally conducted over the past three (3) years. Attach additional pages if necessary.


Please list any specific topics or issues you would like to see addressed in this seminar.


Important note: A completed attendee profile must accompany the registration form. Thank you.

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