Practitioner Member Assessment Application Form

Practitioner Member Assessment Application Form

Note: To apply for MII Practitioner Member assessment you must be a registered Certified Member and hold a current Practising Certificate.

Name (please print):

Address:

Tel: Mobile:

Email:1

1 All MII communications are by email (except for election materials). The onus is on the member to ensure that the MII has their correct current email address.

Please Indicate Main Area(s) of Practice based on submitted cases:

Agriculture □ Civil and Commercial □ Community □ Construction □ Elder Mediation □

Environment □ Family2 □ Separating Couples □ Insurance □ Healthcare □ Organisational/Workplace □ Professional Negligence □ Restorative Justice □

Other (please specify):

2 Family denotes interfamily disputes (e.g. sibling; parent/adult child etc.) other than separating couples disputes.

Date for Assessment:

Please submit your form and we will revert to you with a proposed date of assessment.

Please ensure that the following items are included with your assessment form:

·  An outline of the 3 cases which you believe showcase your advanced Mediator skills

·  A short personal statement to give a brief overview of your practice and experience and to put the cases into context.

·  Your mediation log

·  Evidence of required participation in Sharing and Learning

·  An outline of your reflective practice and changes in your practice in light of those reflections

·  Completed Practitioner Member Assessment Application Form

·  3Assessment fee of €275.00/St£235.15 (cheque or bank transfer) □

3Fee may be paid in either Euro or Sterling.

Note:

1.  Please refer to Becoming a Practitioner Member section of the MII web site (www.mii/membership/practitioner-membership for further information

2.  Please ensure that you keep a copy of all documentation submitted to the MII.

3.  This form, your cheque and 3 copies of each of the relevant assessment documentation, should be sent to the Registrar, The MII.

The MII Bank Account Details

Payments in Euro

AIB Bank, 100 Grafton Street, Dublin 2, Ireland

IBAN: IE97 AIBK 9310 4717 4580 69

BIC: AIBKIE2D

Sort Code: 93-10-47

Account number: 17458069

When making a transfer please be sure to use your name as a reference so that I can identify the payment when it arrives.

Payments in Sterling

AIB Bank. St Helens, 1 Undershaft, London, EC3A 8AB, UK

IBAN: GB65 AIBK 2385 9012 4900 43

BIC: AIBKIE2D

Sort Code: 23-85-90

Account number 12490043

If you have any queries regarding submission of your application, please contact the MII Registrar at

The Mediators’ Institute of Ireland • Pavilion House • 31 Fitzwilliam Square South • Dublin 2

T: 353 1 609 9190 • E: • W: www.themii.ie