Contractor Application

Contractor Application - Online Form

Introduction
The purpose of this application is to determine if you are qualified to work as an independent contractor for Peninsula Mediation and ADR in our role as a contractor for the Department of the Navy, Social Security Administration, and other federal agencies for whom PMADR is a contractor for mediation and training services. Acceptance as an independent contractor is not guaranteed solely by meeting the qualifications delineated in this application. Final acceptance may also entail a telephonic or in-person interview. Persons who are selected will be notified by mail and will receive a subcontractor packet.

Questions about this application or the requirements herein should be sent by e-mail to:

Office Admin
Instructions
You will be completing the following multi-section form in order to submit to us the required information to process your request. Please follow the instructions on each page and complete the information to the best of your ability. Some items are required and you will not be able to submit your application without them.

You will fill out each section, then click "next" to load the next section, until you reach the "Submit Application" button on the final section. Your information will be retained in the filled out sections while you are working. You can go back and forth within the form and make changes as needed.

DO NOT reload the form or visit another page on this website, your data will be lost and you will have to start over.

Because the application is so long and comprehensive, we suggest downloading the following PDF which represents the entire form. Study it, and if you like, prepare all of the information ahead of time in order to quickly cut and paste into the form fields:

Contractor Application - PreFlight
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Contact Vitals

First Name *
Last Name *
Address *
City *
State *
Zip *
Phone (Work) *
Phone (Mobile) *
Phone (Home)
Phone (Fax)
Email *
Alternate Email
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Pre-requisites (required)

Information
The following are requirements for our contract with Department of the Navy and cannot be waived by PMADR. Other contracts have less stringent requirements, but if you have no federal workplace mediation experience, your application cannot be accepted.
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Mediation Certificate Pre-requisite (required)

Certificate List

Instructions Current mediation certification from an approved state or equivalent program which requires basic and advanced facilitative mediation skills training. Use the options below to attach copies of certificates that show the period of certification and expiration dates.

Multiple upload options are provided. Only one is required.

Accepted filetypes are:

jpg | jpeg | gif | pdf | txt | doc | docx

Mediation Certification 1

Mediation Certification 2

Mediation Certification 3

Mediation Certification 4

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Federal workplace mediation case pre-requisite (required)

Case List

Instructions Applicants must have completed at least 10 facilitative federal workplace mediation cases within the 12-month period immediately preceding the date of this application. Please list these below.

Case 1

Agency/Organization For whom mediation was provided: *

Description of case: *

Date of service *

Outcome if agreement was reached: *

Case 2

Agency/Organization For whom mediation was provided: *

Description of case: *

Date of Service *

Outcome if agreement was reached: *

Case 3

Agency/Organization For whom mediation was provided: *

Description of case: *

Date of Service *

Outcome if agreement was reached: *

Case 4

Agency/Organization For whom mediation was provided: *

Description of case: *

Date of Service *

Outcome if agreement was reached: *

Case 5

Agency/Organization For whom mediation was provided: *

Description of case: *

Date of Service *

Outcome if agreement was reached: *

Case 6

Agency/Organization For whom mediation was provided: *

Description of case: *

Date of Service *

Outcome if agreement was reached: *

Case 7

Agency/Organization For whom mediation was provided: *

Description of case: *

Date of Service *

Outcome if agreement was reached: *

Case 8

Agency/Organization For whom mediation was provided: *

Description of case: *

Date of Service *

Outcome if agreement was reached: *

Case 9

Agency/Organization For whom mediation was provided: *

Description of case: *

Date of Service *

Outcome if agreement was reached: *

Case 10

Agency/Organization For whom mediation was provided: *

Description of case: *

Date of Service *

Outcome if agreement was reached: *

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Degree Pre-requisite (required)

Degree List

Instructions A Bachelor’s degree is required for all mediators and mentors. An Advanced degree in conflict management, organizational management, business administration, communication, social work, education, psychology, law, or a field related to the previous disciplines is strongly preferred. List the college(s)/university(ies) you attended and the degrees awarded.

Degree 1

Degree 2

Degree 3

Degree 4

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Mediation Experience

Experience Descriptions

How many years have you been mediating?

For the last two (2) years, what is your average number of cases per month?

For the last two (2) years, what is your average number of cases per year?

How much of your work history and caseload was in a volunteer capacity and how much was based upon fee for services or salary?

Supporting Documents

Instructions Attach any documentation you have to verify your work history and caseload.

Accepted filetypes are:

jpg | jpeg | gif | pdf | txt | doc | docx

File Upload

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Case Based Mediation Experience

Case List

Instructions In what substantive or specific areas have you conducted mediation cases, i.e., workplace (federal, state, municipal, or private sector), family (private practice or court referred), civil (private practice or court referred), commercial, other? What is the approximate number of cases conducted in each area in the last two years? Please list this information below.

Federal workplace cases in the last two (2) years

State or municipal workplace cases in the last two (2) years

Private sector workplace cases in the last two (2) years

Family – private practice cases in the last two (2) years

Family – court referred cases in the last two (2) years

Civil – private practice cases in the last two (2) years

Civil – court referred cases in the last two (2) years

Federal workplace cases in the last two (2) years

"Other" cases in the last two (2) years

Please Specify

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Other Experience and Information

Other Experience List

Please fill out the experience you have in the following areas

Practice Management and Supervision:

If you have your own practice, describe the management aspects of the practice including any experience supervising the work of other mediators.

Other Experience Relevant to Workplace Disputes or the Federal Sector:

Special Skills (e.g. Sign Language, Languages that You Speak Fluently other than English):

Membership in Professional Organizations:

List the professional organizations to which you belong, whether related to mediation or not. Include any offices, committee memberships, and positions of leadership that you presently hold. Are you listed on the rosters or referral lists of any of these organizations? If so, which organizations? What are the requirements to be on each list? Are you listed on any rosters or referral lists for which you pay a fee, e.g. Mediate.com, others? If so, please specify.

Complaints or Adverse Actions:

Have any complaints ever been filed against you as a mediator or provider of ADR services? If so, when, what was the nature of each complaint, what agency or organization adjudicated each complaint, and what was the disposition or outcome?

Availability to Travel:

In some cases, PMADR is required to use local providers. In other cases, travel may be required. Air travel will be arranged by PMC. We expect you to pre-pay other expenses and submit a voucher for reimbursement in accordance with Joint Travel Regulations? List any limitations on your availability to travel (geographic area, notice, time away from home or your place of work overnight, etc.).

Special Accommodations:

Do you need any special accommodations while traveling, mediating, or training? If so, what are they?

Capability to Participate in Web-based Training and to Submit Documents, Records, and Reports:

Do you have the capability to participate in web-based training? Will you be able to submit all required records and reports via e-mail? What hardware and software will you use?

Facilities to Conduct Mediation:

If facilities cannot be routinely provided by PMC or the agency or organization for which you are providing services, do you have facilities to conduct face-to-face mediation with multiple parties? Can these facilities accommodate persons with special needs?

Security Clearance:

Do you presently have, or have you previously had, any type of government security clearance? If so, what type and for what period of time is/was it valid? If it was terminated, what was the reason for the termination? Are you willing to pay for the nominal cost of fingerprinting necessary to obtain a security clearance?

Codes of Ethics and Standards of Practice:

List any organizations to which you belong that require your compliance with their Codes of Ethics or Standards of Practice.

Professional References:

List the names and contact information of three references, e.g., peers, supervisors, trainees, and/ or clients or sources of referrals for clients.

Professional Liability Insurance: If you have professional liability or malpractice insurance, attach a copy of your current insurance binder.

Accepted filetypes are:

jpg | jpeg | gif | pdf | txt | doc | docx

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Training You Have Completed

Instructions List the primary mediation training you believe qualifies you to provide services as a subcontractor to PMADR. What additional training have you completed within the last five years? Include as much information as possible about the title and type of training, number of hours, dates, trainer’s name, and sponsoring agency or organization. How would you classify the style or philosophy of each training, i.e., facilitative (F), transformative (T), evaluative (E), directive (D), other (O)? Duplicate additional sheets if necessary.

Training Completed - Example 1

Title and Type of training

Trainer and Sponsoring Agency or Organization

Number of Hours

Dates

Style or Philosophy facilitative (F), transformative (T), evaluative (E), directive (D), other (O)

Please Specify

Training Completed - Example 2

Title and Type of training

Trainer and Sponsoring Agency or Organization

Number of Hours

Dates

Style or Philosophy facilitative (F), transformative (T), evaluative (E), directive (D), other (O)

Please Specify

Training Completed - Example 3

Title and Type of training

Trainer and Sponsoring Agency or Organization

Number of Hours

Dates

Style or Philosophy facilitative (F), transformative (T), evaluative (E), directive (D), other (O)

Please Specify

Training Completed - Example 4

Title and Type of training

Trainer and Sponsoring Agency or Organization

Number of Hours

Dates

Style or Philosophy facilitative (F), transformative (T), evaluative (E), directive (D), other (O)

Please Specify

Training Completed - Example 5

Title and Type of training

Trainer and Sponsoring Agency or Organization

Number of Hours

Dates

Style or Philosophy facilitative (F), transformative (T), evaluative (E), directive (D), other (O)

Please Specify

Training Completed - Example 6

Title and Type of training

Trainer and Sponsoring Agency or Organization

Number of Hours

Dates

Style or Philosophy facilitative (F), transformative (T), evaluative (E), directive (D), other (O)

Please Specify

Training Completed - Example 7

Title and Type of training

Trainer and Sponsoring Agency or Organization

Number of Hours

Dates

Style or Philosophy facilitative (F), transformative (T), evaluative (E), directive (D), other (O)

Please Specify

Training Completed - Example 8

Title and Type of training

Trainer and Sponsoring Agency or Organization

Number of Hours

Dates

Style or Philosophy facilitative (F), transformative (T), evaluative (E), directive (D), other (O)

Please Specify

Training Completed - Example 9

Title and Type of training

Trainer and Sponsoring Agency or Organization

Number of Hours

Dates

Style or Philosophy facilitative (F), transformative (T), evaluative (E), directive (D), other (O)

Please Specify

Training Completed - Example 10

Title and Type of training

Trainer and Sponsoring Agency or Organization

Number of Hours

Dates

Style or Philosophy facilitative (F), transformative (T), evaluative (E), directive (D), other (O)

Please Specify

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Training You Have Presented

Instructions List the mediation training you presented within the last five years. Include the title and type of training; your role, i.e., principal trainer, co-trainer, role-play coach, etc.; style or philosophy of each training, i.e., facilitative (F), transformative (T), evaluative (E), directive (D), other (O); number of hours; dates; number of attendees; and, if you presented this training for someone, who was the sponsoring agency or organization? Duplicate additional sheets if necessary. Attach any evaluations you received within the last year from attendees or supervisors.

Training Presented - Example 1

Title and Type of training

Sponsoring Agency or Organization

Your Role

Number of Hours

Dates

Number of Attendees

Style or Philosophy facilitative (F), transformative (T), evaluative (E), directive (D), other (O)

Please Specify

Training Presented - Example 2

Title and Type of training

Sponsoring Agency or Organization

Your Role

Number of Hours

Dates

Number of Attendees

Style or Philosophy facilitative (F), transformative (T), evaluative (E), directive (D), other (O)

Please Specify

Training Presented - Example 3

Title and Type of training

Sponsoring Agency or Organization

Your Role

Number of Hours

Dates

Number of Attendees

Style or Philosophy facilitative (F), transformative (T), evaluative (E), directive (D), other (O)

Please Specify

Training Presented - Example 4

Title and Type of training

Sponsoring Agency or Organization

Your Role

Number of Hours

Dates

Number of Attendees

Style or Philosophy facilitative (F), transformative (T), evaluative (E), directive (D), other (O)

Please Specify

Training Presented - Example 5

Title and Type of training

Sponsoring Agency or Organization

Your Role

Number of Hours

Dates

Number of Attendees

Style or Philosophy facilitative (F), transformative (T), evaluative (E), directive (D), other (O)

Please Specify

Training Presented - Example 6

Title and Type of training

Sponsoring Agency or Organization

Your Role

Number of Hours

Dates

Number of Attendees

Style or Philosophy facilitative (F), transformative (T), evaluative (E), directive (D), other (O)

Please Specify

Training Presented - Example 7

Title and Type of training

Sponsoring Agency or Organization

Your Role

Number of Hours

Dates

Number of Attendees

Style or Philosophy facilitative (F), transformative (T), evaluative (E), directive (D), other (O)

Please Specify

Training Presented - Example 8

Title and Type of training

Sponsoring Agency or Organization

Your Role

Number of Hours

Dates

Number of Attendees

Style or Philosophy facilitative (F), transformative (T), evaluative (E), directive (D), other (O)

Please Specify

Training Presented - Example 9

Title and Type of training

Sponsoring Agency or Organization

Your Role

Number of Hours

Dates

Number of Attendees

Style or Philosophy facilitative (F), transformative (T), evaluative (E), directive (D), other (O)

Please Specify

Training Presented - Example 10

Title and Type of training

Sponsoring Agency or Organization

Your Role

Number of Hours

Dates

Number of Attendees

Style or Philosophy facilitative (F), transformative (T), evaluative (E), directive (D), other (O)

Please Specify

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Your Mediation Style

Mediation Style Questions

Instructions Please answer the following questions about your mediation style.

Describe how you conduct mediation.

What is your role in the process? What are the dos and don’ts of your style?

Why have you chosen your predominant style in comparison to other styles or methods?

Explain the facilitative and evaluative styles of mediation, as you understand them.

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Your Mentoring Experience

Mentoring Experience Questions

Instructions Please fill out the following information about your mentoring experience.

Mentoring Training

List the specific the trainings you have completed in mentoring other mediators. Include the title of the training, number of hours, dates, trainer’s name, and sponsoring agency or organization.

Mentoring Experience

How many mediators have you mentored, for what nature or types of cases, and in what setting or context? Were these cases a part of a private practice or were they conducted on behalf of any government agency or private sector organization?

Your Mentoring Philosophy

Describe your mentoring philosophy to include the role and expectations of the mentor and the role and expectations of those being mentored.

Mentoring References

Please list the names and contact information for three (3) persons for whom you have served as a mentor.

Upload Certification Docs

Instructions Attach any certificates for this training or, if you were certified based upon other criteria, attach any certificate issued by your state designating you as a Mentor.

Accepted filetypes are:

jpg | jpeg | gif | pdf | txt | doc | docx

File Upload

Upload Your Contract

Instructions Attach any contracts you use for this training.

Accepted filetypes are:

jpg | jpeg | gif | pdf | txt | doc | docx

File Upload

Scenarios

Instructions How would you respond or intervene in the following federal workplace disputes in which your role is mentor/co-mediator and the person you are mentoring is your co-mediator?

Scenario 1

An employee and his supervisor are mediating a complaint that the employee was not promoted because of his race. After several grueling hours of mediating, your co-mediator says, “I think if this were to be litigated, your employee has a much stronger case.”

Scenario 2

A female employee and her male supervisor are mediating a complaint that the supervisor has permitted several male employees to take time off during the day to get a hair cut, but told her she had to make her hair appointments on her own time. Your female co-mediator says, “I can understand your supervisor’s point of view. You know as well as I do that it takes us longer at the hairdresser than it does for a man to get a haircut.”

Scenario 3

An employee feels that he has been unjustly discharged because his supervisor supports a Republican candidate for mayor in the local community and the employee has encouraged others to vote for the Democratic candidate. Your co-mediator says, “This is a simple legal matter. The law is very clear about this type of activity. Both of you have violated the law and could be disciplined.”

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Agreement

By checking this box I agree that the information I have submitted is accurate and honest. I understand that my application will be reviewed and that I will be contacted and my information verified in order to proceed with the process.

I agree.

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Contractor Application